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Vol.  CXXXIX,  No.  5         MAY,  1910  No.  458 

THE 

AMERICAN  JOURNAL  OF 
THE  MEDICAL  SCIENCES 

Edited  by  A.  O.  J.  KEL|,Y,  M.D. 

VACCINE  THERAPY  IN  COLON-BACILLUS  INFECTION  OF  t^H¥'^NARY  TRA( 

By  FRANK  BILLINGS,  M.D.  /V^/ .  •  625 

PAROXYSMAL  ARTERIOSPASM  WITH    HYPERTENSION  IN  THE  GASTRIC  CRISES 

OF  TABES.    By  LEWELLYS  F.  BARKER,  M.D  631 

A  STUDY  OF  FIVE  HUNDRED  AND  FIFTY  CASES  OF  TYPHOID  FEVER  IN  CHILDREN. 

By  SAMUEL  S.  ADAMS,  A.M.,  M.D.  638 

ARTERIAL  HYPERTENSION.   By  ARTHUR  R.  ELLIOTT,  M.D  648 

THE  USE  AND  ABUSE  OF  GASTRO-ENTEROSTOM Y.   By  JOHN  B.  DEAVER,  M.D.,  LL.D.  655 

HAVE    WE    MADE   ANY    PROGRESS    IN    THE    TREATMENT    OF  GONORRHOEA? 

By  L.  BOLTON  BANGS,  M.D.        .         .         .         .         .         .         .......         .         .         .  664 

HELMINTHIASIS  IN  CHILDREN.    By  OSCAR  M.  SCHLOSS,  M.D.        .        .        .       v.        .  675 

AN   EPIDEMIC  OF  NOMA.   By  HAROLD  NEUHOF,  M.D  705 

THE  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD  SERUM:  ITS  SIGNIFICANCE  AND 

ITS  DIAGNOSTIC  VALUE.    By  RICHARD  WEIL,  M.D.        .        .        .        .        .  .714 

THE  WASSERMANN  AND  NOGUCHI  COMPLEMENT-FIXATION  TEST  IN  LEPROSY. 

By  HOWARD  FOX,  M.D   .  725 

THE   EFFECT  OF  TUBERCULOSIS  ON    INTRATHORACIC  RELATIONS.    By  ALBERT 

PHILIP  FRANCINE,  A.M.,  M.D.     .         .         ,   .  732 


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ANNOUNCEMENTS 


New  (6th)  Edition  Just  Ready  Thoroughly  Revised 

A  PRACTICAL  TREATISE  ON 

Fractures  and  Dislocations 

By  LEWIS  A.  STIMSON,  B.  A.,  M.  D. 

Professor  of  Surgery  in  Cornell  University  Medical  College,  New  York  City 
Octavo,  876  pages,  with  361  engravings  and  65  full-page  plates.   Cloth,  $5.00,  net 


A  new  edition  of  a  work  universally  recognized  as  first  and  final  authority  by  the 
medical  and  legal  professions  of  America  as  well  as  by  the  courts.  It  is  unique  in 
literature  as  covering  two  cognate  classes  of  common  and  urgent  injuries  that  every 
general  practitioner  and  surgeon  must  be  qualified  to  treat.  For  their  proper  manage- 
ment, as  well  as  to  avoid  or  defend  lawsuits,  which  are  peculiarly  apt  to  arise  in  such 
cases,  every  medical  man  owes  it  to  his  patients  and  himself  to  command  the  latest 
and  most  authoritative  knowledge,  offered  in  this  great  work.  Its  wide  acceptance  is 
shown  in  the  demand  for  repeated  editions.  The  author  has  again  revised  it  to  date, 
including  the  rarest  as  well  as  the  common  injuries  of  both  classes.  He  has  presented 
the  results  of  his  own  immense  experience  interwoven  with  knowledge  derived  from 
familiarity  with  American  and  foreign  literature  on  these  subjects,  so  that  the  work  is 
cosmopolitan  in  scope.    Fully  illustrated. 


New  (3d)  Edition  Just  Ready  Thoroughly  Revised 

THE  DISEASES  OF 

INFANCY  AND  CHILDHOOD 

By  HENRY  KOPLIK,  M.  D. 

Pediatrist  to  the  Mount  Sinai  Hospital,  late  Attending  Physician  to  the 
Good  Samaritan  Hospital,  etc.,  New  York 

Octavo,  925  pages,  with  208  engravings  and  36  plates  in  colors  and  monochrome. 

Cloth,  $5.00,  net 


The  sterling  qualities  of  this  volume  both  as  a  student's  text-book  and  as  a  complete 
practical  work  of  reference  for  the  physician  have  been  widely  appreciated.  The 
author  has  left  nothing  undone  to  make  this  new  edition  thoroughly  representative  of 
the  best  and  latest  knowledge.  Every  line  has  been  revised,  much  has  been  eliminated, 
more  has  been  added,  and  many  chapters  have  been  recast  or  rewritten.  The  advances 
in  pathology,  diagnosis  and  treatment  in  the  last  few  years  have  clarified  many  hitherto 
obscure  points  that  will  be  found  well  presented  in  this  new  issue.  Among  the  many 
changes  of  high  interest  and  importance  may  be  mentioned  the  improvements  in  the 
diagnosis  and  treatment  of  the  infections,  the  latest  advances  in  infant  feeding,  the 
management  of  gastric  and  nervous  diseases,  including  the  new  treatment  of  menin- 
gitis, the  chapters  on  cystitis  and  pyelitis,  and  the  new  sections  on  tuberculosis,  idiocy, 
dwarfism  and  neurotic  conditions.  A  feature  has  been  made  of  improved  methods  of 
examination  and  therapy.  As  young  children  cannot  aid  the  diagnostician  by  describ- 
ing their  symptoms,  much  depends  on  their  expression.  Accordingly  the  highly 
artistic  and  life-like  drawings  for  which  this  work  is  notable  are  a  practical  aid. 
Many  new  engravings  and  plates  of  this  character  have  been  added.  In  a  word,  the 
book  has  been  so  thoroughly  revised  that  the  changes  and  improvements  make  it  well 
worth  securing  even  by  those  who  have  a  previous  edition. 


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COMPLETE  WORK  JUST  READY 

MODERN  MEDICINE 

ITS  THEORY  AND  PRACTICE 

In  original  contributions  by  Eminent  American  and 
Foreign  Authors 

Edited  by  WILLIAM  OSLER,  M.D. 

Regius  Professor  of  Medicine  in  Oxford  University,  England ;  Honorary  Professor  of  Medi- 
cine in  Johns  Hopkins  University,  Baltimore ;  formerly  Professor  in  the  University 
of  Pennsylvania,  Philadelphia,  and  in  McGill  University,  Montreal 

In  seven  octavo  volumes  of  about  900  pages  each,  illustrated.   Price  per  volume,  cloth,  $6.00 
net ;  leather,  $7.00,  net ;  half  morocco,  $7.50,  net.   Subscriptions  received 
only  for  the  whole  work.   Prospectus  on  request 


The  publication  of  the  seventh  volume  completes  the  greatest  work  on  practical 
medicine  ever  offered  to  the  profession.  Dr.  Osier's  preeminent  position  has  enabled 
Tiim  to  secure  articles  from  the  leaders  in  every  department.  Their  cooperation  under 
a  skillfully  devised  plan  has  resulted  in  the  creation  of  a  complete  library  of  present- 
day  medicine  within  the  convenient  compass  of  about  6,ooo  pages,  adequately  illus- 
trated. Each  volume  is  indexed,  and  the  seventh  contains  a  general  index  to  the 
whole,  so  that  the  latest  authoritative  information  on  any  point  is  immediately  at  com- 
mand. For  a  work  of  such  paramount  value  and  usefulness  a  phenomenal  demand 
was  assured  and  it  was  therefore  possible  to  fix  a  price  low  enough  to  meet  the  con- 
venience of  every  practitioner  who  aims  to  qualify  in  full  measure  for  his  responsi- 
bilities. 

New  (13th)  Edition  Just  Ready  Thoroughly  Revised 

A  TEXT-BOOK  OF 

PRACTICAL  THERAPEUTICS 

By  HOBART  AMORY  HARE,  M.  D. 

Professor  of  Therapeutics  and  Materia  Medica,  Jefferson  Medical  College  of  Philadelphia. 

Octavo,  960  pages,  with  122  engravings  and  4  full=page  colored  plates 
Cloth,  $4.00,  net;  leather,  $5,00,  net;  half  morocco,  $5.50,  net 


The  Johns  Hopkins  Hospital  Bulletin. 

No  other  medical  text-book  which  has 
appeared  in  the  last  twenty  years  has  had 
such  a  deserved  success  as  Hare's  Thera- 
peutics. It  is  one  of  the  few  medical 
text-books  which  can  be  thoroughly  com- 
mended and  which  every  practitioner  will 
find  useful. 

The  Albany  Medical  Annals. 

The  most  compact,  concise  and  interest- 
ing text-book  published  on  therapeutics. 


The  Medical  Record. 

The  success  and  popularity  of  this  work 
are  due  to  its  sterling  merit  and  to  the 
author's  skill  in  supplying  the  right  kind 
of  information  on  the  best  methods  of 
treating  disease.  It  not  only  states  what 
measures  should  be  adopted,  but  also  tells 
how  and  when  to  employ  them,  and  when 
not  to  employ  them. 

The  Buffalo  Medical  Journal. 

The  ideal  text-book  on  practical  thera- 
peutics. 


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1 


Volume  I,  Just  Ready 


New  (3d)  Edition 


Volume  II,  Very  Shortly 


A  MANUAL  OF 

OPERATIVE  SURGERY 

By  SIR  FREDERICK  TREVES,  F.  R.  C.  S. 

Sergeant-Surgeon  to  H.  M.  the  King,  Consulting  Surgeon  to  the  London  Hospital 
REVISED  BY  THE  AUTHOR  AND 

JONATHAN  HUTCHINSON,  Jr.,  F.  R.  C.  S. 

Surgeon  to  the  London  Hospital 

In  two  octavo  volumes.    Volume  I  contains  775  pages,  193  engravings  and  17  plates 
De  Luxe  edition,  half  morocco,  $6.50,  net,  per  volume 


In  this  work  the  most  eminent  English  surgeon  of  the  present  time  covers  the 
operative  side  of  surgery,  giving  full  details  of  the  procedures  which  in  his  experience 
have  proved  to  yield  the  best  results  in  the  various  conditions.  The  reader  is  thus 
spared  the  task  of  weighing  the  multiplicity  of  operations  that  have  been  practised. 
In  each  section  are  included  instructions  as  to  the  preparation  of  the  patient  and  the 
after-treatment  of  the  case.  The  demand  for  a  work  of  such  value  has  exhausted  two 
editions,  and  now  a  new  one,  thoroughly  revised  to  date  and  largely  rewritten  and 
re-illustrated,  has  been  prepared  by  the  author's  colleague.  A  limited  quantity  has 
been  secured  for  sale  in  the  United  States. 


Fifth  Edition  Thoroughly  Revised 

THE  PRINCIPLES  AND 

PRACTICE  OF  GYNECOLOGY 

By  E.  C.  DUDLEY,  A.  M.,  M.  D. 

Professor  of  Gynecology  in  the  Northwestern  University  Medical  School,  Chicago 
Octavo,  806  pages,  431  illustrations,  (75  in  colors)  and  20  plates.  Cloth,  $5.00,net ;  leather,  $6.00,  net 


The  Ohio  State  Medical  Journal. 


This  edition  is  the  strongest  issue  yet  of 
a  very  popular  work.  Modern  surgical 
technique  is  fully  described,  and  the 
details  of  all  operative  procedures  are 
clearly  set  forth.     Major  operations  are 


described  step  by  step,  and  are  illustrated' 
with  an  abundance  of  original  drawings 
made  for  their  special  place  and  purpose. 
One  of  the  most  practical  text-books  on 
gynecology. 


New  (2d)  Edition 


Just  Ready 


Thoroughly  Revised' 


OBSTETRICS 

A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 

By  DAVID  J.  EVANS,  M.  D. 

Lecturer  on  Obstetrics,  McGill  Univ.,  Montreal;  Fellow,  Obstetrical  Society  of  London. 
I2mo,  43'J  pages,  with  169  illus.'rations,  partly  in  colors.   Cloth,  $2.25,  net 


The  Indianapolis  Medical  Journal.  The  Buffalo  Medical  Journal. 

An  excellent  treatise  done  with  sim-  One  of  the  best  manuals  on  obstetrics- 
plicity  and  thoroughness.  with  which  we  are  familiar. 


PHILADELPHIA 

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New  (2d)  Edition 


Just  Ready 


Thoroughly  Revised 


DISEASES  OF  THE 

NOSE,  THROAT  AND  EAR 

By  WILLIAM  LINCOLN  BALLENGER,  M.D. 

Prof,  of  Otology,  Rhinology  and  Laryngology,  College  of  Physicians  &  Surgeons,  Chicago 
Octavo,  950  pages,  492  engravings,  mostly  original,  and  17  plates.    Cloth,  $5.50  net 


American   Journal  of 

The  second  edition  of  Ballenger's  book 
has  been  not  only  very  greatly  enlarged, 
but  every  page  shows  evidence  of  careful 
revision.  The  work  may  be  thoroughly 
commended  as  suitable  for  purposes  not 


the   Medical  Sciences. 

only  of  the  student  and  practitioner,  but 
also  of  the  specialist,  who  desires  a  work 
of  reference  in  which  he  may  have  access 
to  the  most  recent  advances  in  the  sub- 
jects of  which  it  treats. 


New  (2d)  Edition  Just  Ready  Thoroughly  Revised 

THE  PRINCIPLES  AND 

PRACTICE  OF  MEDICINE 

FOR  PRACTITIONERS  AND  STUDENTS 

By  ARTHUR  R.  EDWARDS,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Northwestern 
Univ.  Medical  School,  Chicago 

Octavo,  1246  pages,  with  100  engravings  and  21  plates.   Cloth,  $5.50,  net;  leather,  $6.50,  net 


Medical  Record. 


A  complete  treatise  on  the  principles 
and  practice  of  medicine,  nervous  dis- 
eases being  included.  The  articles  are 
very  practical.  This  is  especially  true  of 
the    sections    devoted    to  therapeutics. 


Throughout  the  book  the  logical  in  thera- 
peutics is  laid  stress  on  in  distinction  to 
purely  empirical  methods.  A  well- 
balanced  treatise,  fulfilling  all  the  demands 
of  the  student  and  practitioner. 


Fifth  Edition 


Thoroughly  Revised 


A  PRACTICAL  TREATISE  ON 


MEDICAL  DIAGNOSIS 

By  JOHN  H.  MUSSER,  M.D. 

Professor  of  Clinical  Medicine,  Univ.  of  Penna.;  ex-President  American  Medical  Association 


Octavo,  1213  pages,  395  engravings,  63  plates.   Cloth,  $6.50,  net;  leather,  $7.50  net,  half  morocco,  $8.00,  net 


The  Canada  Lancet.  The  Memphis  Medical  Monthly. 

It  is  a  work  that  every  practitioner  will  The  leading  and  standard  work  on  its 

find  of  immense  service,  and  those  teach-  subject.       Every     accepted     method  of 

ers  who  use  it  for  their  classes  will  find  clinical     and     bedside     investigation  is 

-i    •               ,1          £-        .    i         ,  •  described    clearly   and    fully,    and  every 

their    own    labors    facilitated    and    the  «■    .  •         ,    r        *     iU  \     u:  r 

.  effort  is  made  to  render  the  teachings  of 

records  of  their  students  at  examination  the  book  of  such  practical  nature  as  to  be 

reflecting  credit  on  all  concerned.  readily  available  to  the  practitioner. 


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New  (Fifth)  Edition  Just  Ready  Thoroughly  Revised 

A  TEXT-BOOK  OF  THE 


DISEASES  OF  THE  EAR 

By  PROF.  DR.  ADAM  POLITZER 

Imperial-Royal  Professor  of  Aural  Therapeutics  in  the  University  of  Vienna,  etc. 

Translated  at  the  personal  request  of  the  author,  and  edited  by 
Milton  J.  Ballin,  Ph.B.,  M.D.,  and  Clarence  L.  Heller,  M.D. 

Large  octavo,  892  pages,  with  337  original  illustrations.   Cloth,  $8.00,  net 


The  Journal  of  Ophthalmology  and  Otolaryngology. 

Probably  the  most  exhaustive  work  yet  quotations  from  and  references  to  oto- 
published  on  otology ;  indeed,  it  could  logical  literature.  It  is  sufficient  to  say 
almost  be  called  a  cyclopedia  of  otology.  that  valuable  additions  have  been  made 
In  addition  to  the  author's  own  opinion  and  that  the  work  is  in  every  way  credit- 
and   experience,  the   work   contains  550     able  to  both  the  author  and  publishers. 

NEW  WORK  JUST  READY 

A  TEXT-BOOK  OF 

SURGICAL  DIAGNOSIS 

FOR  STUDENTS  AND  PRACTITIONERS. 

By  EDWARD  MARTIN,  M.  D. 

Professor  of  Clinical  Surgery,  University  of  Pennsylvania,  Philadelphia 
Octavo,  772  pages,  with  446  engravings,  largely  original,  and  18  full-page  plates.   Cloth,  $5.50,  net 


American   Journal   of  the   Medical  Sciences. 

A  careful  reading  of  this  work,  and  an  usefulness.     If  there   is   a   better  work 

equally    careful    comparison    with    other  on  surgical  diagnosis  we  are  not  familiar 

treatises  on  surgical  diagnosis,  are  amply  with  it.    It  will  be  a  valuable  addition  to 

convincing  as  to  its  unusual  merit  and  every  working  surgical  library. 

NEW  WORK  JUST  READY 

Text-book  of  Protozoology 

By  GARY  N.  CALKINS,  Ph.  D. 

Professor  of  Protozoology  in  Columbia  University,  New  York 
Octavo,  349  pages,  with  125  illustrations  and  4  full=page  plates  in  colors.    Cloth,  $3.25,  net 


Journal  of  the  American  Medical  Association. 

A  comprehensive  and  authoritative  pres-  facts  to  medical  problems.    The  need  that 

entation  of  modern  protozoology.  Pro-  has  existed  for  a  book  of  this  kind  is  well 
ressor  Calkins  has  wisely  chosen  to  base  c  ,    ,       -n    r  ~     .    ,  . 

the   book   on   broad   biologic   principles,  satisfied    by    Professor    Calkins  work, 

knowledge  of  which  is  essential  for  the  which    admirably    fulfils    all  reasonable 

successful    application    of    protozoologic  demands  from  the  medical  point  of  view. 


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New  (3d)  Edition 


Enlarged  and  Thoroughly  Revised 


Just  Ready 


ORGANIC  AND  FUNCTIONAL 

NERVOUS  DISEASES 

A  TEXT-BOOK  OF  NEUROLOGY 

By  M.  ALLEN  STARR,  M.  D.,  Ph.  D.,  LL.  D. 

Professor  of  Neurology,  College  of  Physicians  and  Surgeons,  New  York 
Ex-President,  American  Neurological  Association  and  New  York  Neurological  Society. 

Octavo,  91 1  pages,  300  engravings  and  29  plates.    Cloth,  $6.00,  net;  leather,  $7.00,  net 


The  Alienist  and  Neurologist. 

The  work  is  comprehensive  and  practi- 
cal. Within  its  covers  is  the  latest  and 
most  authoritative  information,  elaborately 
illustrated,  of  modern  neuro-symptomatol- 
ogy,  pathology  and  therapeutics. 


The  Journal  of  Nervous  and  Mental  Diseases. 

It  is  a  presentation  of  the  personal 
experience  of  over  twenty-five  years  of 
neurological  practice. 

The  Johns  Hopkins  Hospital  Bulletin. 

The  best  of  its  kind  which  has  appeared 
in  this  country. 


New  (2d)  Edition  Enlarged  and  Thoroughly  Revised  Just  Ready 

TYPHOID  FEVER 

AND  OTHER  EXANTHEMATA 
By  H.  A.  HARE,  M.  D.,  B.  Sc.,  and  E.  J.  G.  BEARDSLEY,  M.  D. 

Of  the  Jefferson  Medical  College,  Philadelphia 
Octavo,  398  pages,  with  26  engravings  and  2  plates.   Cloth,  $3.25,  net 


Journal  of  the  Southern  Medical  Association. 


The  reviewer  doubts  whether  in  any 
other  text-book  on  medicine  so  many  con- 
ditions of  intense  interest,  yet  withal  so 


seldom  mentioned  or  described,  can  be 
found  presented  in  logical  sequence  for 
the  consideration  of  the  profession. 


New  (Eighth)  Edition  Just  Ready  Thoroughly  Revised 

THE 

Principles  of  Bacteriology 

A  PRACTICAL  MANUAL  FOR  STUDENTS  AND  PHYSICIANS 

By  A.  C.  ABBOTT,  M.D. 

Professor  of  Bacteriology  and  Hygiene  in  the  University  of  Pennsylvania 
12  mo,  631  pages,  with  100  illustrations,  26  being  in  colors.  Cloth,  $2.75,  net. 


American   Journal    of  the   Medical  Sciences. 

It  has  been  since  its  birth  the  most  the  latest  trustworthy  opinions  regarding 

popular    students'    book.      It    has    been  a  branch  of  medicine  that  is  advancing 

brought  thoroughly  abreast  of  the  times,  with   rapid   strides.     As   heretofore,  the 

and  now  contains  the  important  facts  and  book  may  be  warmly  recommended. 


PHILADELPHIA 

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THE  DISEASES  AND  SURGERY  OF  THE 

GENITO-URINARY  SYSTEM 

By  FRANCIS  S.  WATSON,  M.  D. 

Senior  Visiting  Surgeon  at  the  Boston  City  Hospital;  Lecturer  on  Geni to-urinary 
Surgery  in  the  Harvard  Medical  School,  and 

JOHN  H.  CUNNINGHAM,  Jr.,  M.  D. 

Assistant  Visiting  Surgeon  to  the  Boston  City  Hospital;  Member  of  the  American 
Association  of  Genito-urinary  Surgeons 

In  two  very  handsome  octavo  volumes  containing  1101  pages,  with  454  engravings  and  47 
full=page  colored  plates,  mostly  from  original  drawings.    Price  for  the  complete  work, 
extra  cloth,  $12,00,  net.    In  half  Persian  morocco,  gilt  top,  de  luxe,  $17.00,  net 


The  American  Journal  of  Urology. 

The  illustrations  and  the  general  make- 
up are  magnificent,  and  every  department 
of  genito-urinary  surgery  is  treated  in  a 
clear,  full  and  comprehensive  manner. 
We  know  of  no  other  work  as  complete 
and  as  comprehensive  in  its  scope,  either 
in  the  English  or  in  any  other  language. 


Zeitschrift  fur  Urologie. 

This  work  should  have  a  foremost  place 
in  the  international  literature  of  this 
field.  As  examples  of  admirable  qualities 
may  be  mentioned  the  fine  anatomical 
descriptions  which  precede  the  separate 
chapters,  the  magnificent  illustrations, 
and  the  clear  and  terse  descriptions  of  the 
steps  of  different  operative  procedures. 


Second  Edition 


Thoroughly  Revised 


A  TEXT-BOOK  OF 


THE  PRACTICE  OF  MEDICINE 

FOR  STUDENTS  AND  PRACTITIONERS 

By  HOBART  AMORY  HARE,  M.  D.,  B.  Sc. 

Professor  of  Therapeutics  and  Mat.  Med.,  Jefferson  Medical  College,  Philadelphia;  Laureate 
of  the  Royal  Academy  of  Medicine  in  Belgium  and  of  the  Medical  Society  of  London 

Octavo,  1132  pages,  131  engravings  and  II  plates.  Cloth,  $5.00,  net;  leather,  $6.00,  net;  half 

morocco,  $6.50,  net 


The  New  York  State  Journal  of  Medicine. 


The  scope  of  the  book  is  broad  and 
inclusive ;  the  entire  list  of  medical  dis- 
eases is  considered.    There  is  a  refresh- 


ing rationality  in  the  treatment,  and  it  is 
evident  that  the  author  has  sustained  his 
reputation  as  an  eminent  therapeutist. 


Third  Edition  Thoroughly  Revised 

THE 

PRACTICE  OF  OBSTETRICS 

BY  AMERICAN  AUTHORS 

Edited  by  CHARLES  JEWETT,  M.D. 

Professor  of  Obstetrics  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y. 
Octavo,  820  pages,  484  engravings,  (46  in  colors),  and  36  colored  plates.   Cloth,  $5.00  net;  leather,  $6.00,  ne 


The  American  Journal  of  Obstetrics. 

Without  being  too  voluminous,  the  work 
is  complete,  and  attains  a  uniform  high 
level  of  authority.  It  is  very  freely 
illustrated. 


Surgery,  Gynecology  and  Obstetrics. 

The  book  is  one  that  sounds  the  note  of 
authority.  The  matter  is  presented  sim- 
ply, concisely  and  after  a  plan  well 
adapted  to  the  teacher's  and  student's  use. 


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A  PRACTICAL  TREATISE  ON 

DISEASES  OF  THE  SKIN 

By  J.  NEVINS  HYDE,  M  D. 

Professor  of  Dermatology  and  Venereal  Diseases  in  the  University  of  Chicago,  Medical 
Department,  (Rush  Medical  College) 

New  (8th)  edition,  thoroughly  revised  and  much  enlarged.   Octavo,  1126  pages,  with  223  engravings  and 
58  full=page  plates  in  colors  and  monochrome.   Cloth,  $5.00,  net;  leather,  $6.00,  net 


Journal  of  Cutaneous  Diseases. 

The  author's  sound  conservatism, 
knowledge  of  the  literature,  and  vast  ex- 
perience as  a  clinician  and  a  teacher 
speak  forth  from  every  page,  and  make 
the  book  second  to  none  as  a  safe  and 
sane  guide  in  dermatological  matters.  No 
one  who  is  engaged  in  special  derma- 


N. 


With  each  edition  Bacon's  Otology  is, 
if  possible,  improved  in  its  arrangement 
and  contents.  The  book  has  long  since 
been  recognized  as  the  representative 
American  manual  of  otolosry.  This  edition, 
like  each  of  the  previous  editions,  shows 


tological  or  in  general  practice  can  afford 
to  be  without  this  book. 

Bulletin  of  the  Johns  Hopkins  Hospital. 

Dr.  Hyde's  treatise  is  now  the  most 
thorough  one  in  English,  as  well  as  most 
excellent.  It  is  abundantly  supplied  with 
illustrations. 


every  evidence  of  careful  revision  of  the 
text  on  the  part  of  the  author.  Every 
subject  is  brought  thoroughly  up  to  date. 
No  better  book  could  be  recommended  to 
the  student  or  practitioner  who  wishes  an 
authoritative  presentation  of  otology. 


ew  (5th)  Edition  Just  Ready  Thoroughly  Revised 

A  MANUAL  OF  OTOLOGY 

By  GORHAM  BACON,  A.  M.,  M.  D. 

Professor  of  Otology  in  the  College  of  Physicians  and  Surgeons,  New  York 
WITH  AN  INTRODUCTORY  CHAPTER  BY 

CLARENCE  J.  BLAKE,  M.  D. 

Professor  of  Otology  in  Harvard  Medical  School,  Boston 
12mo,  503  pages,  with  145  engravings  and  12  colored  plates.   Cloth,  $2.25,  net 

American  Journal   of   the   Medical  Sciences. 


Fourth  Edition  Thoroughly  Revised 

A  MANUAL  OF 

Diseases  of  the  Nose&  Throat 

By  CORNELIUS  G  COAKLEY,  M.D. 

Clinical  Prof,  of  Larynologyin  the  Univ.  and  Bellevue  Hospital  Medical  College,  New  York 
12mo,  604  pages,  with  126  engravings  and  7  colored  plates.  Cloth,  $2.75,  net 


The  Bulletin  of  the  Medical  and  Chirurgical 
Faculty   of  Maryland. 

A  concise,  practical  book  for  the  under- 
graduate and  general  practitioner.  Each 
topic  is  set  forth  in  a  simple  and  com- 
prehensive way.  The  man  in  active  prac- 
tice who  requires  a  ready  reference  will 
find  this  book  especially  valuable. 


The  Ohio  State  Medical  Journal. 

This  work  is  well  arranged  in  text, 
concise  in  treatment,  clear  and  lucid  in 
style,  and,  above  all,  practical.  The  cuts 
and  illustrations  are  well  selected  and 
executed.  It  is  a  valuable  contribution  to 
medical  literature. 


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New  (2d)  Edition       Greatly  Enlarged  and  Thoroughly  Revised 


Just  Ready 


THE  PRINCIPLES  AND 

PRACTICE  OF  SURGERY 

By  GEORGE  E.  BREWER,  M.D. 

Professor  of  Clinical  Surgery,  College  of  Physicians  and  Surgeons,  New  York 
Octavo,  908  pages,  415  engravings,  14  plates.  Cloth,  $5.00,  net 


The  Johns  Hopkins  Hospital  Bulletin. 


Dr.  Brewer's  position  as  one  of  the 
leading  surgeons  of  America  gives  to  this 
text-book   an    authority    which    at  once 


makes  it  valuable  to  the  student.  As  a 
work  in  one  volume,  it  is  very  complete 
and  satisfactory. 


Third  Edition  Thoroughly  Revised 

A  TEXT-BOOK  OF 

Physiological  Chemistry 

By  CHARLES  E.  SIMON,  M.D. 

Professor  of  Clinical  Pathology  in  the  Baltimore  Medical  College:  author  of 
Simon's  Clinical  Diagnosis,  etc. 

Octavo.  490  pages,  Cloth,  $3.25  net 


The  American  Journal  of  the  Medical  Sciences. 

This  work  is  particularly'  valuable  in 
the  classroom  in  giving  students  a  clear 
comprehension  of  the  laboratory  side  of 
physiological  chemistry.  It  is  clearly 
written  and  is  a  very  useful  text-book. 


The  Johns  Hopkins  Hospital  Bulletin. 

This  book  is  undoubtedly  one  of  the 
best  of  its  kind.  The  author  presents  the 
subject  in  a  clear  and  easy  way.  It  can 
be  recommended  to  the  student  as  well  as 
to  the  practitioner. 


Fourth  Edition  With  Appendix 

A 

DICTIONARY  OF  MEDICINE 

AND  THE  ALLIED  SCIENCES 

By  ALEXANDER  DUANE,  M.D. 

of  New  York,  Reviser  of  Medical  Terms  for  Webster's  International  Dictionary 

Octavo,  678  double=columned  pages,  colored  plates  and  thumb=index. 
Cloth,  $3  00,  net;  full  flexible  leather,  $4.00,  net 


The  Denver  Medical  Times.  The  Buffalo  Medical  Journal. 

Contains  a  surprising  amount  of  useful  It  is  one  of  the  most  practical  of  the 
information  tersely  and  accurately  told. smaller  dictionaries;  its  type  is  ^lain,  its 
The  vocabulary  is  complete  in  every  definitions  are  clear  and  its  arrangement 
practical  essential.  excellent. 


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ORIGINAL  ARTICLES  TO  APPEAR  IN  THE  ISSUE 
FOR  JUNE,  1910 

The  Treatment  of  Intestinal  Indigestion  in  Children  on  the  Basis  of  the  Exam 
ination  of  the  Stools  and  Caloric  Values.    By  John  Lovett  Morse,  M.D., 
Assistant  Professor  of  Pediatrics  in  the  Harvard  Medical  School,  Boston. 

The  Treatment  of  Hemorrhage  from  Gastric  Ulcer.  By  J.  Kaufmann,  M.D.* 
Professor  of  Clinical  Medicine  in  the  College  of  Physicians  and  Surgeons,  Columbia 
University,  New  York. 

The  Pathogenesis  of  the  Toxemias  of  Pregnancy.  By  James  Ewing,  M.D.,  Pro- 
fessor of  Pathology  in  the  Cornell  University  Medical  College,  New  York. 

Chronic  Family  Jaundice.  By  Wilder  Tileston,  M.D.,  Assistant  Professor  of  Medi- 
cine in  Yale  University,  New  Haven. 

A  Study  of  Murmurs  in  Pulmonary  Tuberculosis.  By  Charles  Montgomery,  M.D., 
of  Philadelphia. 

The  Effect  of  Tuberculosis  on  Intrathoracic  Relations.  By  Albert  P.  Francine 
M.D.,  Instructor  in  Medicine  in  the  University  of  Pennsylvania,  Philadelphia. 

The  Radiographic  Diagnosis  and  Classification  of  Early  Pulmonary  Tuberculosis. 

By  L.  Gregory  Cole,  M.D.,  of  New  York. 

Two  Cases  of  Solitary  False  Neuromas— Probably  Malignant.  By  Edward  M. 
Foote,  M.D.,  of  New  York. 

Typhoid  Spermatocystitis  and  Prostatitis,  and  their  ^elation  to  Chronic  Typhoid 
Bacilluria.  By  John  W.  Marchildon,  M.D.,  Assistant  Professor  of  Bacteriology 
in  the  St.  Louis  University,  St.  Louis. 

How  Far  is  Heredity  a  Cause  of  Aural  Disease?  By  B.  Alexander  Randall, 
M.D.,  Clinical  Professor  of  Otology  in  the  University  of  Pennsylvania,  Philadelphia. 


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11 


PARKE,  DAVIS  &  CO.'S 

Soft-Mass  Pills 


are  worthy 
of  your  specification. 

Easily  flattened  between 
thumb  and  finger. 

These  pills  consist  of  a  soft  interior  mass, 
enveloped  (with  a  single  exception)  in  a  thin  coating  of 
chocolate.  They  may  be  flattened  between  the  thumb  and 
finger  as  one  might  flatten  a  piece  of  putty. 

Our  Soft-Mass  Pills  dissolve  readily  in  the  digestive  tract. 
They  keep  well  and  do  not  lose  strength  under  proper  con- 
ditions of  storage.  They  are  attractive  in  appearance.  They 
are  strictly  true  to  label. 

In  the  soft-mass  process  no  heat  is  applied,  hence  such 
volatile  substances  as  camphor,  the  valerianates,  the  essential 
oils,  etc.,  are  preserved  in  full  measure. 


THE 

( Chocolate-Coated 

No.  892— Ferrous  Carbonate  (Blaud),  5  grs., 

round,  uncoated. 
No.  967-Calhartic  Compound,   U.   S.  P. 

Eighth  Revision. 
No.  968  — Cathartic  Compound,  Improved. 
No.  969  -  Quinine  Sulphate,  2  grs. 
No.  970- Cascara  Compound   No.  3  (Dr. 

Hinklei. 

No.  97  I  —  Ferrous  Carbonate  (Blaud),  5  grs., 
U.  S.  P  Eighth  Revision. 

No.  97  5-Cholelith  (round). 

No.  977— Ferrous  Carbonate  (  Blaud) .  Modi- 
fied. 

No.  981— Ferrous  Carbonate  (Blaud)  Com- 
pound, R  "  C." 

No.  982  Ferrous  Carbonate  with  Nux  Vom- 
ica. 

No.  983-  Blaud  and  Strychnine  Compound, 
R  "  B." 

No.  984— Aloin,  Strychnine  and  Belladonna, 
R  "A." 

No.  985 — Aloin,  Strychnine  and  Belladonna 
Compound,  N.  F. 


LIST. 

Except  No.  892.) 

No.  986  -  Cathartic   Compound  Granules, 

%  gr. 

No.  987  — Emmenagogue,  Improved. 
No.  988-Evacuant. 

No.  989 — Ammonium  Valerianate,  1  gr. 
No.  990 — Camphor,  Opium  and  Lead  Ace- 
tate. 

No.  991 — Camphor,  Opium  and  Tannin. 
No.  992— Opium  and  Camphor,  N.  F. 
No.  993 — Quinine,  Iron  and  Zinc  Valerian- 
ates. 

No.  994— Quinine  Valerianate,  2  grs. 

No.  995-Salol,  2^  grs. 

No.  996   Salol,  5  grs. 

No.  997— Salol  and  Phenacetine. 

No.  998-Warburg  Tincture,  N.  F.,  repre- 
senting %  fluidrachm. 

No.  999— Warburg  Tincture,  N.  F.,  repre- 
senting 1  fluidrachm. 

No.  1 000— Warburg  Tincture  without  Aloes, 
N.  F.,  representing  I  fluidrachm. 

No.  1001-Alophen. 


PARKE,  DAVIS  &  COMPANY 

Laboratories:  Detroit,  Mich.,  U.S.A.;  Walkerville,  Ont.;  Hounslow,  Eng. 

Branches:  New  York,  Chicago,  St.  Louis.  Boston,  Baltimore,  New  Orleans,  Kansas  City« 
Minneapolis;  London,  Eng.;  Montreal,  Que.;  Sydney,  N.S.W.;  £ft.  Petersburg, 
Russia;  Bombay,  India;  Tokio,  Japan;  Buenos  Aires,  Argentina. 


PRUNOIDS 

AN  IDEAL  PURGATIVE  MINUS  CATHARTIC  INIQUITIES 
A  real  advance  in  the  therapy  of  intestinal  constipation. 


SENG 


A  STIMULATOR  OF  DIGESTIVE  PROCESSES 
Used  alone  or  as  a  vehicle  to  augment  and  aid  the  natural  functions  of  digestion. 


CACTINA  PILLETS 

CEREUS  GRANDIFLORUS  IN  ITS  MOST  EFFICIENT  FORM 
A  persuasive  Heart  Tonic  to  improve  Cardiac  nutrition. 


sent  tu  phvsiciansV^^        SULTAN  DRUG  CO.,  St.  Louis. 

PEACOCK'S 

BROMIDES 

In  Epilepsy  and  all  cases  demanding  continued  bromide  treat- 
ment, its  purity,  uniformity  and  definite  therapeutic  action 
insures  the  maximum  bromide  results  with  the  minimum 
danger  of  bromism  or  nausea. 


CHIONIA 

is  a  gentle  but  certain  stimulant  to  the  hepatic  functions  and 
overcomes  suppressed  biliary  secretions.  It  is  particularly 
indicated  in  the  treatment  of  Biliousness,  Jaundice,  Consti- 
pation and  all  conditions  caused  by  hepatic  torpor. 


PEACOCK  CHEMICAL  CO.,  St.  Louis,  Mo. 


FREE  SAMPLES  AND 
LITERATURE  TO  THE 
PROFESSION,  UPON 

request.  PHARMACEUTICAL  CHEMISTS 


13 


STRUMOUS 
DISORDERS 

■■■K^i^^^^BMMiBMHMMMil  with  their  train  of  symptoms  point- 
ing to  faulty  or  perverted  metabolism,  demand  remedies  capable  of  readjusting 
normal  cell  processes.    Of  these 

IODIA 

is  strongly  suggested  as  the  standard  tonic-alterative.  Clinical  experience,  ex- 
tending over  many  years,  has  shown  that  it  possesses  striking  individuality  as 
a  reliable  means  to  the  end  of  stimulating  cellular  functions,  promoting  the 
elimination  of  waste  products  and  re-establishing  metabolic  activity. 

IODIA,  therefore,  has  a  well-defined  field  of  application  in  Syphilitic, 
Scrofulous  and  Cutaneous  Diseases,  Rheumatic  and  Gouty  Ail- 
ments, and  wherever  a  reliable  altero-reconstructive  is  required. 

BATTLE  &  CO. 

(ESTABLISHED  1875) 
LONDON  ST.   LOUIS  PARIS 

I  


-•is* 


14 


Probitin  Pills 


Obviate  biliary  infection  and  stagnation 
Reduce  swelling  and  spasm  of  the  gall-ducts 
Modify  calculi  and  favor  their  expulsion. 


Jithovin  C&psules 


Render  the  urine  antibacterial, clear,  acid 
Lessen  gonorrheal  difficulties  (tenesmus) 
Diminish  the  occurrence  of  complications. 


Jinusol  Suppositories 


Relieve  hemorrhoidal  pain  and  congestion 
Exert  atonic  action  on  inflamed  mucosae 
Promote  healing  of  the  vascular  structures. 


2i 


L  iterature 


Monosodium-Diethyl-Barbituric  Acid 


A  freely  soluble  hypnotic  for 
use  by  mouth,  by  rectum  and 
subcutaneously.  Being  read- 
ily absorbed  and  rapidly  ex- 
creted, it  is  distinguished  by 

PROMPT  AND  RELIABLE 
SOPORIFIC  EFFECT 

FREEDOM  FROM  CUMULA- 
TIVE TOXIC  ACTIONS 

Superior  to  the  sparingly  soluble 
diethyl-barbituric  acid  of  Mering. 
Advantageously  replaces  chloral  in 
threatening  delirium  tremens;  use- 
ful in  the  treatment  of  morphinism. 

Dose  :  5  to  15  grains  (1  to  3  tablets) 

Liter  at  u 

SCHERING  &  GLATZ 


Brom-Isovaleric-Acid-Borneolester 


Combines  the  action  of  vale- 
rian with  that  of  bromine,  but  is 
readily  taken  and  well  borne, 
causing  no  eructation  or  other 
untoward  symptoms.  Exhibits 

VIGOROUS  SEDATIVE  AND 
NERVINE  EFFECT 

INNOCUOUSNESS  EVEN  IN 
LARGE  DOSES 

Decidedly  effective  in  neuras- 
thenic and  hysterical  conditions, 
obviating  subjective  difficulties — 
mental  and  physical  fatigue,  head- 
ache, nervousness,  insomnia,  etc. 

Dose  :  1  to  3  pearls  several  times  daily 

re  from 

New  York 


15 


IflgUgflME'  *  a  p°werM-  non- 

~  '  ~   toxic  antiseptic.  It 

is  a  saturated  solution  of  boric  acid,  rein- 
forced by  the  antiseptic  properties  of  ozonif- 
erous  oils.  It  is  unirritating,  even  when 
applied  to  the  most  delicate  tissue.  It  does 
not  coagulate  serous  albumen.  It  is  par- 
ticularly useful  in  the  treatment  of  abnormal 
conditions  of  the  mucosa,  and  admirably  suited 
for  a  wash,  gargle  or  douche  in  catarrhal 
conditions  of  the  nose  and  throat 

There  is  no  possibility  of  poisonous  effect 
through  the  absorption  of  Listerine. 

Listerine  Dermatic  Soap  is  a  bland,  unirritating 
and  remarkably  efficient  soap. 

The  important  function  which  the  skin  performs  in  the 
maintenance  of  the  personal  health  may  easily  be  impaired  by 
the  use  of  an  impure  soap,  or  by  one  containing  insoluble 
matter  which  tends  to  close  the  pores  of  the  skin,  and  thus 
defeats  the  object  of  the  emunctories;  indeed,  skin  diseases  may 
be  induced,  and  existing  disease  greatly  aggravated  by  the  use 
of  an  impure  or  irritating  soap.  When  it  is  to  be  used  in 
cleansing  a  cutaneous  surface  affected  by  disease,  it  is  doubly 
important  that  a  pure  soap  be  selected,  hence  Listerine 
Dermatic  Soap  will  prove  an  effective  adjuvant  in  the  general 
treatment  prescribed  for  the  relief  of  various  cutaneous  diseases. 

"The  Inhibitory  Action  of  Listerine"  a  128 -page  pamphlet 
descriptive  of  the  antiseptic,  and  indicating  its  utility  in  medical,  surgical 
and  dental  practice,  may  be  had  upon  application  to  the  manufacturers, 
Lambert  Pharmacal  Co.,  St.  Louis, 
Missouri,  but  the  best  advertisement 
of  Listerine  is  


fflSlMWE 


16 


CONTENTS. 


ORIGINAL  ARTICLES. 

Vaccine  Therapy  in  Colon-bacillus  Infection  of  the  Urinary  Tract  .  625 

By  Frank  Billings,  M.D.,  Professor  of  Medicine  in  the  Rush  Medical 
College,  in  Affiliation  with  the  University  of  Chicago. 

Paroxysmal  Arteriospasm  with  Hypertension  in  the  Gastric  Crises 

of  Tabes  631 

By  Lewellys  F.  Barker,  M.D.,  Professor  of  Medicine  in  the  Johns 
Hopkins  University,  and  Physician-in-Chief  to  the  Johns  Hop- 
kins Hospital,  Baltimore. 

A  Study  of  Five  Hundred  and  Fifty  Cases  of  Typhoid  Fever  in 


Children   638 

By  Samuel  S.  Adams,  A.M.,  M.D.,  Professor  of  the  Theory  and  Prac- 
tice of  Medicine  and  of  Diseases  of  Children  in  the  Georgetown 
University,  Washington,  D.  C. 

Arterial  Hypertension  648 

By  Arthur  R.  Elliott,  M.D.,  Professor  of  Medicine  in  the  Post- 
graduate Medical  School,  Chicago. 

The  Use  and  Abuse  of  Gastro-enterostomy  655 

By  John  B.  Deaver,  M.D.,  LL.D.,  Surgeon-in-Chief  to  the  German 
Hospital,  Philadelphia. 

Have  We  Made  Any  Progress  in  the  Treatment  of  Gonorrhoea?  .  664 

By  L.  Bolton  Bangs,  M.D.,  Consulting  Surgeon  to  the  Belle vue  and 
St.  Luke's  Hospitals,  New  York. 

Helminthiasis  in  Children   675 

By  Oscar  M.  Schloss,  M.D.,  Assistant  to  the  Chair  of  Pediatrics  in 
the  New  York  University  and  Belle  vue  Hospital  Medical  College; 
Assistant  Visiting  Physician  to  the  Out-patient  Department  of 
the  Babies'  Hospital,  New  York. 

An  Epidemic  of  Noma  705 

By  Harold  Neuhof,  M.D.,  Adjunct  Surgeon  to  the  New  York 
Hebrew  Infant  Asylum. 

The  Antitryptic  Activity  of  Human  Blood  Serum:  Its  Significance 

and  Its  Diagnostic  Value  714 

By  Richard  Weil,  M.D.,  of  New  York. 
The  Wassermann  and  Noguchi  Complement-fixation  Test  in  Leprosy  725 

By  Howard  Fox,  M.D.,  of  New  York. 
The  Effect  of  Tuberculosis  on  Intrathoracic  Relations  732 

By  Albert  Philip  Francine,  A.M.,  M.D.,  Instructor  in  Medicine 
in  the  University  of  Pennsylvania. 


VOL.  139.  NO.  5.  MAY.  1910.  21 


11 


CONTENTS 


REVIEWS. 


The  Principles  of  Pathology.  Vol.  I.  General  Pathology.  By  J.  George 
Adami,  M.D.,  LL.D.,  F.R.S.  Vol.  II.  Systemic  Pathology.  By 
J.  George  Adami  and  Albert  G.  Nicholls,  M.A.,  M.D.,  D.Sc,  F.R.S. 

(Can.)  745 

A  Text-book  of  Physiological  Chemistry  for  Students  of  Medicine.  By 

John  H.  Long,  M.S.,  Sc.D  749 

Chemical  and  Microscopical  Diagnosis.  By  Francis  Carter  Wood,  M.D.  .  750 
Lehrbuch  der  klinischen  Diagnostik  innerer  Krankheiten.    Edited  by 

Paul  Krause,  M.D  750 

Cataract  Extraction.    By  H.  Herbert,  F.R.C.S  .751 

A  Text-book  of  Diseases  of  the  Ear.    By  Macleod  Yearsley,  F.R.C.S.   .     .  752 


PROGRESS   OF  MEDICAL  SCIENCE. 

MEDICINE. 

UNDER  THE  CHARGE  OF 

WILLIAM  OSLER,  M.D.,  and  W.  S.  THAYER,  M.D. 


The  Effect  of  Digitalis  on  the  Ventricular  Pate  in  Man   753 

Auricular  Fibrillation   754 

The  Etiology  of  Beri-beri   754 

The  Physiology  of  the  Immediate  Reaction  of  Anaphylaxis      ....  755 

.Jaundice  in  Pneumonia   756 

On  the  Quantity  of  Glycuronic  Acid  in  the  Urine  in  Health  and  Disease    .  750 

The  Cultivation  of  the  Organism  of  Infantile  Paralysis   756 

Rat-bite  Fever   757 

"  Nail-palpation"  of  the  Arterial  Wall   757 

A  Previously  Undescribed  Symptom  of  Tetany   758 


SURGERY. 

UNDER  THE  CHARGE  OF 

J.  WILLIAM  WHITE,  M.D.,  and  T.  TURNER  THOMAS,  M.D. 


Atlo-axoid  Fracture  Dislocation   758 

Malignant  Degeneration  of  Benign  Diseases  of  the  Breast   759 

The  Treatment  of  Cystitis,  Especially  Severe  Postoperative  Cases  .     .     .  759 

The  Operative  Treatment  of  Wounds  of  the  Lungs   760 

Stasis  Hemorrhages  Resulting  from  Compression  of  the  Thorax  and 

Abdomen   761 

An  Experimental  and  Literary  Study  Concerning  the  Manner  and  Path- 
way of  Extension  of  Urogenital  Tuberculosis     .   761 

The  Treatment  of  Bone  and  Joint  Tuberculosis  by  the  X-rays  ....  762 


CONTENTS 


111 


THERAPEUTICS. 

UNDER  THE  CHARGE  OF 

SAMUEL  W.  LAMBERT,  M.D 

Diet  in  Typhoid  Fever   763 

Antidiphtheritic  Serum  and  Antidiphtheritic  Globulin  Solutions    .     .     .  764 

Tuberculin  Treatment  of  Tuberculosis   764 

The  Treatment  of  Gastroptosis   765 

The  Treatment  of  Gastric  Disease  with  Aluminum  Silicate       ....  765 

Substitutes  for  Digitalis   766 

The  Treatment  of  Acute  Pulmonary  (Edema   766 

Chloral  Hydrate  as  a  Local  Application   766 


PEDIATRICS. 

UNDER  THE  CHARGE  OF 

LOUIS  STARR,  M.D.,  and  THOMPSON  S.  WESTCOTT,  M.D. 

Unusual  Persistence  in  the  Secretion  of  Colostrum   767 

Dried  Milk  as  a  Food  for  Infants   767 

Cyclic  or  Recurrent  Vomiting  with  Hypertrophic  Stenosis  of  the  Pylorus    .  768 

An  Epidemic  of  Acute  Poliomyelitis   769 

The  Dwarf  Tapeworm,  an  Intestinal  Parasite  in  Children   769 


OBSTETRICS. 

UNDER  THE  CHARGE  OF 

EDWARD  P.  DAVIS,  A.M.,  M.D. 

The  Diagnosis  of  Puerperal  Septic  Infection   770 

Modification  of  Peripheral  Sensation  during  Pregnancy   771 

Ovariotomy  and  Myomectomy  Early  in  Pregnancy,  with  Full  Term 

Delivery   771 

Ovarian  Cyst  with  Twisted  Pedicle  Complicating  Pregnancy    .     .     .  .771 

Artificial  Reproduction  of  the  Amniotic  Liquid  during  Labor  ....  772 
The  Results  of  Pregnancy  Occurring  after  Operation  for  the  Correction 

of  Retroflexion   772 


GYNECOLOGY. 

UNDER  THE  CHARGE  OF 

J.  WESLEY  BOVEE,  M.D. 

An  Ovarian  Abscess  Containing  a  Lumbricoid  Worm  772 

The  Choice  of  Operations  for  Retrodisplacements  of  the  Uterus  .  .  .  773 
The  Endometrium  and  Some  of  its  Variations  773 


iv 


CONTENTS 


Factors  which  Contribute  to  a  Reduction  in  Mortality  in  Abdominal 


Surgery  .......  773 

The  Age  of  Menstruation  in  Egyptian  Girls   774 

The  Anatomy  of  Tubal  Convolutions  and  the  Mechanism  of  Tubal  Occlu- 
sion  774 

Removal  of  an  Unusually  Large  Ovarian  Tumor   774 

Enucleation  of  Uterine  Myomas;  Why  and  When  Performed  ....  774 


OPHTHALMOLOGY. 

UNDER  THE  CHARGE  OF 

EDWARD  JACKSON,  A.M.,  M.D., 

AND 

T.  B.  SCHNEIDEMAN,  A.M.,  M.D. 


The  Treatment  of  Detachment  of  the  Retina   775 

Myopia  and  Light  Sense   776 

Report  upon  103  Cases  of  Magnet  Extraction   776 

Etiology  of  Subacute  and  Tardy  Infection  Following  Operations  .     .     .  776 

Nervous  Asthenopia  from  Electric  Light ;   Use  of  Yellow  Glasses      .     .  777 

Trachoma  in  the  Abruzzi,  Italy   777 

Subcutaneous  Injections  of  Alcohol  in  Blepharospasm  and  Spastic 

Entropion   777 

Helmholt's  Theory  of  Accommodation   777 


PATHOLOGY  AND  BACTERIOLOGY. 

UNDER  THE  CHARGE  OF 

WARFIELD  T.  LONGCOPE,  M.D., 

ASSISTED  BY 

G.  CANBY  ROBINSON,  M.D. 


The  Nature  of  Antitrypsin  in  the  Blood  Serum  and  its  Mode  of  Action     .  778 

The  Venous  Pulse  under  Normal  and  Pathological  Conditions      .     .     .  778 

The  Cause  of  Arteriosclerosis   779 

Changes  in  the  Chromaffin  System  in  Cases  of  Unexplained  Postoperative 

Death   780 


THE 

AMERICAN  JOURNAL 

OF  THE  MEDICAL  SCIENCES. 

MAY,  1910. 
ORIGINAL  ARTICLES. 

VACCINE  THERAPY  IN  COLON-BACILLUS  INFECTION  OF 
THE  URINARY  TRACT.1 

By  Frank  Billings,  M.D., 

PROFESSOR  OF  MEDICINE  IN  THE  RUSH  MEDICAL,  COLLEGE,  IN  AFFILIATION  WITH  THE 
UNIVERSITY  OF  CHICAGO. 

Colon  bacilluria  occurs  in  fully  50  per  cent,  of  all  cases  of  bacteri- 
uria.  The  condition  may  be  unattended  with  perceptible  effect, 
either  local  or  systemic.  Patients  may  suffer  from  dysuria  with  fre- 
quent urination  and  the  colon  bacilluria  may  be  the  only  recognized 
morbid  condition.  Usually  the  bladder  irritation  is  ascribed  to  the 
hyperacid  urine,  but  it  may  continue  when  the  urine  is  rendered 
alkaline.  That  the  colon  infection  is  the  chief  cause  of  the  bladder 
irritation  is  presumptively  proved  by  the  relief  of  all  symptoms  coin- 
cident with  the  disappearance  of  the  bacteria  from  the  urine. 

Colon  bacilluria  may  be  present  with  recognizable  morbid  changes 
in  the  urinary  tract;  the  bacteria  are  either  the  cause  or  are 
closely  related  to  the  disease  process.  The  morbid  anatomical 
change,  probably,  frequently  preexists  in  the  mucous  membrane 
of  some  portion  of  the  urinary  tract.  The  urethra,  prostate,  ureter, 
kidney  pelvis,  and  kidney  may  be  involved.  A  urinary  calculus  may 
preexist  and  also  may  result  from  a  colon  bacilluria.  Colon  urinary 
infection  may  be  present  with  tuberculosis  of  the  urinary  tract  and 
apparently  aggravates  the  associated  morbid  anatomy,  and  intensifies 
the  disturbance  of  the  urinary  apparatus  and  the  general  symptoms. 
It  may  also  rarely  be  present  with  and  aggravate  the  local  disturbance 
and  general  symptoms  of  gonococcic  infection  of  the  deeper  urinary 

1  Read  at  a  meeting  of  the  Medical  Society  of  the  State  of  New  York,  January  26,  1910. 

VOL,  139,  NO,  5. — MAY,  1910. 


626    billings:  vaccine  therapy  in  colon-bacillus  infection 


tract;  of  pyogenic  streptococcic  and  staphylococcic,  proteus,  influen- 
zal, typhoid-bacillus,  and  other  bacterial  infections  of  the  bladder 
and  kidney  pelvis.  Prostatitis,  cystitis,  ureteritis,  pyelitis,  and 
pyelonephritis  may  occur  with  colon  bacilluria  alone  and  as  a  mixed 
infection,  especially  in  tuberculosis  of  the  urinary  tract.  Chronic 
arthritis,  myocardial  degeneration,  myalgias,  and  various  other 
systemic  conditions  apparently  may  be  related  to  the  urinary  infec- 
tion. 

Mode  of  Entrance  of  Colon  Bacilli  into  the  Urinary 
Tract.  This  may  be  through  the  urethra  in  the  female  with  or  with- 
out instrumentation,  and  in  the  male  probably  only  by  instrumenta- 
tion. The  prevalence  of  colon  bacilluria  in  people  who  have  never 
had  a  catheter  or  sound  passed  into  the  ureter,  proves  the  existence 
of  other  routes  of  infection.  In  the  \ast  majority  of  patients  the 
source  is  unquestionably  the  gastro-intestinal  tract.  Obstinate 
constipation  or  diarrhea,  attended  with  more  or  less  injury  of  the 
intestinal  mucosa,  renders  the  intestinal  wall  previous  to  the  iDacteria, 
which  may  then  be  carried  by  the  blood  or  lymph  stream  to  the  kid- 
ney, ureter,  and  bladder.  Colon  bacilli  from  this  source  have  been 
proved  to  take  on  more  virulent  characteristics. 

The  diagnosis  of  bacteriuria  is  easily  made  by  microscopic  exami- 
nation. The  character  of  the  bacteria  usually  requires  a  cultural  ex- 
amination of  the  urine.  From  a,  preferably  catheterized,  specimen, 
primary  plate  cultures  should  be  made;  the  final  recognition  of  the 
bacterium  by  subcultural  and  tinctorial  tests  is  a  common  laboratory 
procedure.  A  careful  physical  examination  of  the  patient,  with 
chemical  and  microscopic  study  of  the  urine,  will  enable  one  usually 
to  make  an  anatomical  diagnosis.  One  should  never  fail  to  make  a 
careful  examination  of  the  external  genitals  of  the  patient,  both  male 
and  female,  for  focal  infection.  The  rectum  should  also  be  inspected. 
The  prostate  should  be  palpated,  and  possible  sacculation  of  the 
bladder  by  abnormal  deviations  of  the  uterus  and  by  a  lax  vaginal 
wall  should  be  investigated.  If  indicated,  a  cystoscopic  examination 
and  catheterization  of  the  ureters  should  be  made.  The  greatest 
care  must  be  exercised  to  catheterize  the  ureters.  This  is  especially 
true  when  the  bladder  is  badly  infected.  The  anatomical  diagnosis 
is  most  important  from  the  therapeutic  point  of  view.  If  a  morbid 
condition  of  tissue  exist  which  interferes  with  the  function  of  the 
urinary  apparatus,  no  permanent  benefit  will  result  from  medical 
treatment,  until  as  nearly  as  possible  a  normal  anatomical  condition 
is  brought  about.  Colon  bacilluria  may  not  be  removed  as  long 
as  poor  drainage  of  the  urinary  tract  exists  because  of  sacculation  of 
the  bladder,  enlarged  prostate,  stricture,  pressure  obstruction,  or 
kink  of  the  ureter,  kidney-pelvis  sacculation,  or  if  a  calculus  or  other 
foreign  body  be  present. 

Formerly  the  recognized  treatment  of  colon  bacilluria  consisted 
preferably  in  prolonged  rest  in  bed,  a  copious  liquid  diet  of  milk, 


billings:  vaccine  therapy  in  colon-bacillus  infection  627 

soups,  broths,  etc.,  and  the  use  of  urinary  antiseptics — of  which 
hexamethylenamine  is  the  best.  By  this  method  treatment  was  long, 
extended  to  months,  and  the  result  was  often  poor.  For  the  last 
five  years  in  the  medical  clinic  of  Rush  Medical  College  associated 
with  the  medical  wards  of  the  Presbyterian  Hospital  and  the  labora- 
tory of  the  Memorial  Institute  for  Infectious  Diseases,  bacteriuria 
has  been  carefully  studied  and  many  patients  have  been  treated 
with  autogenous  vaccines.  The  work  has  been  carried  on  by  the 
clinical  department  of  the  college  and  hospital.  I  have  received 
most  valuable  cooperation  and  aid  from  my  colleagues  and  assistants. 
The  bacterial  cultures  and  autogenous  vaccines  have  been  made 
chiefly  by  Dr.  D.  J.  Davis,2  of  the  medical  department,  and  now  an 
assistant  in  the  Memorial  Institute  for  Infectious  Diseases. 

When  possible  the  agglutination,  opsonic  index,  bacteriolysis, 
and  the  leukocytic  blood  reaction  were  studied  in  each  patient. 
The  observation  of  other  reporters  as  to  the  character  of  the  bacteri- 
uria has  been  confirmed.  Those  suffering  from  infection  of  the 
urinary  tract  due  to  the  colon  organism  comprise  more  than  50  per 
cent,  of  the  patients  with  urinary  infection.  Frequently  the  gono- 
coccus  was  obtained  with  the  colon  infection  from  the  prostate  or  semi- 
nal vesicles  by  stripping  those  organs  with  the  finger  in  the  rectum. 
Undefined  bacteria  were  sometimes  found  with  the  colon;  occa- 
sionally the  unknown  organism  would  be  obtained  only  in  plate 
cultures,  failing  to  grow  in  anerobic  or  aerobic  subcultures.  In 
some  instances  the  unknown  bacterium  persisted  in  the  urine  after 
the  colon  bacillus  had  disappeared  and  the  patient  was  symptom- 
free. 

Colon-bacillus  infection  with  tuberculosis  of  the  urinary  tract 
occurred  in  two  patients;  the  great  discomfort  occasioned  by 
bladder  pain,  frequent  urination,  and  septic  fever  was  almost 
entirely  relieved  by  the  disappearance  of  the  colon  infection  after 
autogenous  vaccination.  Two  patients  suffering  from  essential 
hematuria  with  colon  infection  have  been  treated  by  vaccination. 
Tn  one,  a  woman  aged  twenty-four  years,  intermittent  hematuria 
had  existed  for  six  years  or  more.  A  moderate  pyuria  existed. 
Repeated  examination  of  the  urinary  sediment  failed  to  reveal 
tubercle  bacilli.  Animal  inoculation  with  the  urinary  sediment  was 
negative.  The  ophthalmo-tuberculin  test  was  negative.  Cysto- 
scopic  examination  revealed  a  normal  bladder  mucosa.  The 
ureteral  catheter  entered  the  right  ureter  with  difficulty  and  the  drop 
by  drop  fluid  obtained  contained  blood,  leukocytes,  and  colon  bacilli. 
The  left  ureter  was  normal  and  the  freely  flowing  urine  was  prac- 
tically normal.  In  June,  1907,  a  right  nephrotomy  was  made;  the 
urine  from  the  kidney  pelvis  contained  red  cells  and  leukocytes  and 


2  See  report  by  Dr.  David  John  Davis,  "Immune  Bodies  in  Urinary  Infections  with  Colon 
Bacilli  and  Treatment  by  Inoculation,"  Journal  of  Infectious  Diseases,  1909,  VI,  224. 


628    billings:  vaccina  therapy  in  colon-bacillus  infection 

the  colon  bacillus.  The  mucosa  of  the  pelvis  was  thickened  and 
congested.  The  kidney  capsule  stripped  off  normally  and  a  section 
of  the  cortex  showed  histologically  interstitial  diffuse  nephritis. 
The  kidney  pelvis  was  packed  with  gauze  and  later  was  daily  injected 
with  argyrol  solution,  which  penetrated  to  the  bladder.  Hemor- 
rhages recurred  before  the  external  wound  had  healed  and  afterward. 
Six  months  later,  in  January,  1908,  the  patient  was  again  taken  into 
the  hospital  and  injections  of  autogenous  colon  vaccines  were  given 
every  seven  to  ten  days  until  April,  1908.  Hemorrhage  ceased. 
Since  that  time  the  urine  is  blood-free  except  for  a  few  red  cells  in 
the  centrifuged  sediment.    No  urinary  symptoms  remain. 

A  physician  of  fifty-eight  who  always  has  enjoyed  good  health, 
suffered  from  hematuria  without  pain  in  August,  1909.  In  October 
cystoscopy  revealed  a  normal  bladder  mucosa,  bloody  urine  flowing 
from  the  right  ureteral  orifice,  and  normal  urine  from  the  left 
ureter.  Ureteral  catheterization  was  negative  for  obstruction  or 
stone  and  the  x-rays  also  were  negative.  Probable  tumor  of  the  kid- 
ney was  diagnosticated.  Later  he  was  admitted  to  the  Presbyterian 
Hospital.  The  physical  examination  revealed  a  good  general  condi- 
tion. The  urine  contained  much  free  blood,  many  leukocytes,  no 
casts,  and  was  acid  in  reaction.  A  pure  culture  of  colon  bacilli  was 
obtained  from  the  urine.  A  milky  fluid  obtained  by  stripping  the 
prostate  showed  many  pus  cells  and  a  few  Gram-negative  intra- 
cellular biscuit-shaped  diplococci.  The  prostate  was  stripped  every 
three  or  four  days  until  no  discharge  was  obtained.  The  patient 
was  treated  with  the  autogenous  colon  vaccine  every  seven  days. 
The  blood  disappeared  from  the  urine  after  the  third  vaccination. 
The  urine  remains  blood-free  and  the  patient  is  apparently  well. 

In  September  19,  1908,  a  physician,  aged  twenty-nine  years,  was 
seized  with  anuria,  and  uremic  convulsions,  which  were  partially  re- 
lieved the  first  day.  Headache,  vomiting,  occasional  mild  convulsions 
continued  for  six  days.  The  scant  urine  contained  a  good  deal  of 
pus,  but  no  casts  or  blood.  October  21, 1908,  he  was  admitted  to  the 
Presbyterian  Hospital.  The  general  examination  revealed  no  per- 
ceptible morbid  condition  of  heart,  bloodvessels,  lungs,  or  abdominal 
organs.  The  arterial  tension  was  120  mm.  The  eye-grounds  were 
normal.  The  urine  was  acid,  contained  many  polynuclear  leukocytes 
(60  per  c.mm.  of  urine),  no  casts,  no  red  cells,  and  a  trace  of  nucleo- 
albumin.  Many  bacilli  were  seen  and  a  pure  culture  of  colon  bacilli 
was  obtained.  The  history  revealed  the  probability  that  the  colon 
infection  of  the  bladder  had  existed  for  five  years.  During  that  time 
albuminuria  was  present  for  two  years  and  thereafter  occasionally 
only.  A  month  preceding  the  convulsions  he  was  conscious  of 
lessened  strength  and  endurance,  dull  headaches,  anorexia,  and 
lessened  excretion  of  urine.  Autogenous  colon  vaccination  was  begun 
with  400,000,000  bacteria  on  November  11,  1908.  These  were  re- 
peated every  seven  to  ten  days  until  December  11,  1908,  at  which 


billings:  vaccine  therapy  in  colon-bacillus  infection  629 

time  the  urine  was  almost  free  of  bacteria  and  pus  cells.  The 
patient  continued  the  treatment  at  home.  On  March  23,  1909,  the 
urine  was  sterile  and  pus-free.    The  patient  has  had  no  relapse. 

A  man  aged  thirty-one  years,  suffering  from  tuberculosis  of  the 
urinary  tract  which  began  in  the  right  testis  in  1903,  was  admitted 
to  the  Presbyterian  Hospital  in  October,  1907.  The  right  testis  had 
been  removed  in  1903  and  a  right  nephrotomy  and  curettage  of  the 
kidney  pelvis  was  done  in  June,  1907.  The  patient  was  suffering 
greatly,  although  constantly  narcotized  with  opium.  There  was 
a  septic  temperature.  No  perceptible  evidence  of  tuberculosis  of 
lungs  or  lymph  glands  was  present.  The  urine  was  very  cloudy  and 
discolored  with  abundant  pus,  blood,  and  bacteria.  Tubercle  bacilli 
were  abundant  in  the  urine  sediment.  Per  rectum  a  nodule  in  the 
right  lobe  of  the  prostate  was  tender.  The  right  ureter  could  be  felt 
as  a  thick  tube,  and  this  and  the  resistant  bladder  wall  were  very  ten- 
der. From  the  urine  was  obtained  a  pure  culture  of  the  colon  bacillus. 
The  patient  was  given  absolute  rest  in  bed,  and  received  tuberculin 
(N.T.),  0.001  mg.,  every  seven  or  eight  days  and  coincidently  there- 
with was  vaccinated  with  500,000,000  autogenous  colon  bacilli. 
With  the  third  injection  the  urine  became  colon-free.  Coincident- 
ally  the  urine  became  much  clearer,  containing  less  pus  and  blood. 
The  frequency  of  urination  lessened  from  every  one-fourth  to  one- 
half  hour  to  as  long  as  three  or  four  hours.  The  general  condition 
improved  by  the  disappearance  of  fever  and  sweats  and  the  appetite 
returned.  Opiates  were  discarded.  The  patient  left  the  hospital 
in  December,  1907,  and  has  remained  on  a  farm.  He  has  continued 
to  use  the  injections  of  (N.T.)  tuberculin,  0.001  mg.,  every  seven  to 
ten  days.  Examination  of  the  urine  every  six  months  reveals  the 
presence  of  a  few  leukocytes,  red  cells,  and  small  clumps  of 
tubercle  bacilli.  The  bladder  irritation  is  not  severe  and  the  general 
health  is  good.  Probably  recovery  would  occur  if  the  patient 
could  take  prolonged  rest. 

These  case  reports  suffice  to  illustrate  the  utility  of  colon  vaccine 
therapy.  In  a  later  paper  on  vaccine  therapy  in  bacteriuria  a 
detailed  tabulated  report  will  be  made.  Patients  suffering  with 
pyelitis  with  colon  bacillus  infection  have  recovered  with  autogen- 
ous vaccination  when  there  was  no  obstruction  to  drainage.  Im- 
provement may  occur  under  the  treatment  in  all  cases,  but  entire 
recovery  from  the  colon  bacilluria  will  usually  not  occur  if  there  is 
stagnation  anywhere  in  the  urinary  tract.  If  the  enlarged  prostate 
is  at  fault,  rational  massage  of  that  organ  may  be  all  that  is  necessary. 
If  there  be  deformity  of  the  pelvic  organs  or  distortion  of  the  kidney 
pelvis,  or  the  existence  of  a  urinary  calculus,  surgical  interference 
should  be  instituted. 

Systemic  effects  of  urinary  focal  infection  must  not  be  overlooked. 
A  chronic  infectious  arthritis,  myocardial  degeneration,  so-called 
chronic  muscular  rheumatism,  and  neuritis  may  be  related  to  the 


630    billings:  vaccine  therapy  in  colon-bacillus  infection 

urinary  infection.  The  resistant  epithelial  layer  of  the  urinary  tract 
probably  prevents  toxemia  until  long  continuation  of  the  infection 
causes  injury  of  the  epithelial  layers  and  then  absorption  of  toxins 
may  occur. 

The  bacillus  isolated  from  cases  of  colon  bacilluria  differ  from  each 
other  more  or  less  in  size,  luxuriance  of  growth,  etc.  It  would  seem 
rational,  therefore,  to  use  autogenous  vaccines.  This  is  easily  done. 
Cultures  may  be  made  from  the  urine  after  it  has  been  trans- 
ported a  thousand  miles  to  a  laboratory,  by  one  properly  trained  in 
bacteriological  technique.  We  have  had  no  experience  with  com- 
mercial stock  vaccines  and  no  comparison  may  be  made  of  them 
here. 

The  autogenous  vaccine  may  be  made  by  heating  the  culture  to 
(30°  C.  for  thirty  minutes.  This  has  proved  to  kill  the  bacilli,  as 
shown  by  control  cultures.  Fresh  suspensions  of  the  dead  bacilli 
should  be  used.  Suspensions  more  than  two  weeks  old  may  not 
give  the  same  results.  Usually  the  first  vaccination  is  made  with 
200,000,000  bacilli.  The  subsequent  dosage  may  be  gradually 
increased  until  a  decided  local  and  general  reaction  occurs.  The 
maximum  dose  in  our  work  was  1,000,000,000.  Experience  has 
proved  that  smaller  doses  are  preferable  to  large  ones  with  some 
patients;  5,000,000  to  100,000,000  may  produce  sufficient  reaction 
for  curative  purposes  and  diminish  the  risk  of  a  too  great  reaction. 
Absolute  rest,  much  of  the  time  in  bed,  with  a  copious  fluid  diet, 
chiefly  milk,  shortens  the  course  of  treatment,  reduces  the  risk  of 
chill  with  the  reaction,  and  makes  recovery  more  certain. 

Specificity  of  Vaccine  Therapy.  The  specific  effect  of 
autogenous  colon-bacillus  vaccine  therapy  is  proved  by  the  phe- 
nomena of  reaction.  This  consists  of  the  local  reaction  at  the  point 
of  injection,  which  includes  redness  of  the  skin,  tenderness,  and  swell- 
ing over  an  area  from  one  to  two  inches  square.  This  begins  in  one 
or  two  hours  after  the  injection,  reached  the  maximum  in  twelve 
to  eighteen  hours  and  gradually  disappears  by  the  end  of  forty-eight 
to  seventy-two  hours.  A  general  reaction  occurs  in  two  to  twelve 
hours,  manifested  by  general  malaise,  aching  of  muscles,  bones,  and 
joints,  more  or  less  headache,  more  or  less  fever,  sometimes  preceded 
by  a  chill  and  leukocytosis.  If  the  patient  is  up  and  about  reaction 
is  more  severe — manifested  by  severe  chill  and  fever.  In  many 
patients  there  is  irritation  manifested  by  pain,  aching,  etc.,  of  the 
kidney,  bladder,  joint,  group  of  muscles,  etc.,  respectively,  which 
is  the  seat  of  morbid  change  due  to  the  colon  infection.  The  speci- 
ficity is  further  indicated  by  an  increase  in  the  opsonic  index,  and 
finally  by  an  immunity  manifested  by  the  failure  of  reaction  after 
vaccination  and  the  disappearance  of  the  bacteria  from  the  urine. 
One  should  employ  at  the  same  time  all  rational  measures  to  relieve 
the  patient.  General  hygiene,  personal  cleanliness,  correction  of 
diarrhea  or  constipation,  hematinics  when  necessary,  and,  as  stated 


barker:  gastric  crises  of  tabes 


031 


above,  surgical  or  mechanical  measures  to  correct  anatomical  faults 
which  interfere  with  proper  drainage  of  the  urinary  tract. 

Elsewhere  in  the  paper  I  have  stated  that  colon  baeilluria  is  not 
an  uncommon  occurrence.  In  many  individuals  with  this  urinary 
infection  there  may  be  no  perceptible  effects  from  it.  In  other 
patients  who  suffer  from  some  systemic  infection,  the  conditions 
may  be  ascribed  to  the  existing  colon  baeilluria  without  due  regard 
for  some  other  possible  cause.  This  statement  I  think  is  necessary, 
because  I  have  found  that  colon  infection  of  the  urine  has  been 
brought  into  the  foreground  by  some  physicians  who  have  known 
of  pathological  effects  due  to  it  and  who  may  misinterpret  the  condi- 
tion and  fail  to  look  for  or  to  find  a  real  focal  infection  somewhere 
else  in  the  body.  We  must  not  forget  that  focal  infection  of  the 
tonsils,  of  the  sinuses  of  the  head,  or  of  some  other  mucous  tract  of 
the  body  may  produce  systemic  disease.  Therefore,  while  I  believe 
that  colon  bacillus  infection  of  the  urinary  tract  is  sometimes  a  cause 
of  not  only  local  but  also  of  systemic  disease,  I  would  caution  those 
who  find  this  infection  of  the  urine  not  to  be  led  astray  by  it,  and  to 
make  sure  of  its  relation  to  local  or  systemic  evidence  of  disease  by 
proof  of  its  specificity  by  agglutinative,  phagocytic,  bacteriolytic, 
and  other  tests,  and  at  the  same  time  to  look  for  other  possible 
sources  of  infection  before  the  treatment  is  begun. 


PAROXYSMAL  ARTERIOSPASM  WITH  HYPERTENSION  IN 
THE  GASTRIC  CRISES  OF  TABES. 

By  Lewellys  F.  Barker,  M.D., 

PROFESSOR  OF  MEDICINE  IN  THE  JOHNS  HOPKINS  UNIVERSITY,   AND  PHYSICIAN-IN-CHIEF 
TO  THE  JOHNS  HOPKINS  HOSPITAL,  BALTIMORE. 

Among  the  most  interesting  of  the  problems  which  the  clinician 
has  to  solve  is  that  of  the  interpretation  of  acute  abdominal  pain. 
The  subject  isa  large  one, and  it  is  my  purpose  in  this  communication 
to  deal  with  only  one  phase  of  it — that  indicated  by  the  title  of  this 
paper.  The  topic  may  best  be  approached  by  the  presentation  of  a 
case  which  illustrates  the  main  features  of  the  condition  under 
discussion. 

Hattie  T.,  aged  forty-nine  years,  white,  married  woman,  a  cigar- 
maker,  was  admitted  to  Ward  G,  Johns  Hopkins  Hospital,  October 
9,  1909. 

Her  complaint  was  severe  pain  in  the  back  and  stomach,  and 
headache.  Her  family  history  is  negative.  She  has  been  married 
twenty-four  years.  She  is  the  mother  of  six  children,  two  of  whom 
died  in  infancy.  She  had  had  several  miscarriages,  all  occurring 
early  in  the  pregnancies. 


632 


barker:  gastric  crises  of  tabes 


Except  for  vague  "rheumatic"  pains  for  some  ten  years  she  suffered 
from  no  disease  until  the  present  trouble  began.  About  eight  years 
ago  she  began  to  have  attacks  of  pain  in  the  back,  indigestion,  and 
pains  in  the  joints,  especially  in  the  shoulders  and  knees.  The  pain 
in  the  small  of  the  back  was  tolerably  severe,  and  was  sometimes 
associated  with  nausea.  These  attacks  recurred  at  intervals.  One 
and  one-half  years  ago  she  separated  from  her  husband,  and  since  then 
the  attacks  have  increased  in  number  and  severity.  In  May,  1909,  the 
uterus,  tubes,  and  ovaries  were  removed  in  one  of  the  city  hospitals, 
but  since  the  operation  she  has  been  more  nervous  than  before. 
She  has  suffered  much  from  headache,  frontal  and  vertical,  and  she 
thinks  her  eyesight  has  failed  during  the  last  few  years. 

The  individual  attacks  begin  with  a  feeling  of  a  lump  in  the  throat 
which  cannot  be  swallowed  (globus?).  Vomiting  soon  comes  on, 
so  that  nothing  can  be  retained  in  her  stomach,  and  she  has  extreme 
pain  in  the  back  and  abdomen  and  complains  of  sensitiveness  of  the 
skin  of  the  trunk.  The  pain  is  so  severe  that  she  usually  weeps 
violently  and  tosses  about  in  bed,  grinding  her  teeth.  She  has  never 
lost  consciousness  in  an  attack,  nor  has  there  been  any  disturbance 
of  the  sphincters.  Her  mind  seems  clear  during  the  attacks.  Her 
physician  frequently  was  compelled  to  give  her  morphine  for  the  pain. 
She  has  had  more  or  less  of  the  drug  during  the  last  five  or  six  years. 
Since  about  a  year  ago  there  have  been  nearly  two  attacks  per  week, 
each  lasting  from  a  few  hours  to  three  days.  She  has  noticed  palpi- 
tation of  the  heart  during  some  of  the  attacks. 

On  examination  the  patient  was  found  to  be  somewhat  emaciated; 
the  skin  was  sallow,  the  muscles  soft  and  flabby.  There  was  no 
anemia.  Her  eyes  were  rather  prominent;  there  was  a  tendency 
of  the  eyeball  to  run  ahead  of  the  lid  in  making  von  Graefe's  test. 
The  pupils  were  contracted,  and  reacted  but  little  to  light  or  accom- 
modation, but  it  was  thought  on  admission  that  this  might  be  due 
to  the  morphine.  There  was  no  glandular  enlargement.  There 
was  slight  enlargement  of  the  heart,  the  relative  dulness  extend- 
ing to  the  left  10  cm.  from  the  mid-sternal  line.  The  radial  and 
temporal  arteries  were  tortuous  and  somewhat  thickened.  The 
lungs  were  negative,  except  for  a  moderate  grade  of  emphysema. 
The  stools  contained  some  mucus,  but  no  parasites  or  blood. 

On  the  day  after  admission  she  began  to  suffer  from  severe  pain 
in  the  abdomen  and  back,  lying  in  a  crouched  position,  crying 
constantly,  and  complaining  bitterly.  She  vomited  at  short  inter- 
vals. The  vomitus  was  greenish  in  color  and  was  accompanied  by 
nausea.  Chemical  examination  showed  a  total  acidity  of  42  per  cent. ; 
23  per  cent,  of  free  hydrochloric  acid;  no  lactic  acid;  no  blood.  Ex- 
amination of  the  blood  revealed:  Red  blood  corpuscles,  4,258,000; 
white  corpuscles,  13,800;  hemoglobin,  92  per  cent.  Differential 
count:  Polynuclears,  66  per  cent.;  large  mononuclears,  7  per  cent.; 
lymphocytes,  24  per  cent. ;  and  eosinophiles,  3  per  cent. 


barker:  gastric  crises  of  tabes 


633 


An  examination  of  the  stool  two  days  later  revealed  the  presence 
of  ova  of  Trichocephalus  dispar  and  also  ova  of  Ascaris  lumbricoides. 

On  October  13  I  observed  her  myself  during  a  paroxysm  of  pain. 
The  face  was  very  anxious,  the  lips  somewhat  cyanotic,  the  eyes 
reddened  and  lacrymose.  One  got  the  impression  at  once  that  the 
pain  was  that  of  organic  disease.  The  radial  pulse  was  124,  regular 
but  of  very  high  tension,  feeling  like  a  fine  whipcord  under  the  finger. 
The  blood  pressure  was  measured  at  once  and  found  to  be  about 
190  mm.  Hg.  She  was  given  an  inhalation  of  amyl  nitrite,  and  the 
pressure  fell  at  once  to  90.  A  short  while  after,  however,  the  press- 
ure again  became  high,  going  to  200  and  later  on  to  210  mm.  Hg. 
The  knee-jerks  were  overactive;  the  plantar  reflexes  normal.  The 
pupils  did  not  respond  to  light.  There  was  no  tactile  anesthesia 
of  the  chest,  but  definite  analgesia  in  large  areas  in  the  lower  extremi- 
ties were  present. 

The  urine  contained  no  albumin  or  casts.  Acetone  was  present, 
doubtless  due  to  the  prolonged  vomiting,  though  the  test  for  diacetic 
acid  was  negative.  Palpation  of  the  abdomen  revealed  nothing 
abnormal. 

In  spite  of  the  active  knee-kicks,  I  felt  that  the  character  of  the 
pain  and  the  vomiting,  together  with  the  sluggish  pupils  and  the 
analgesia  of  the  legs,  made  the  diagnosis  of  gastric  crises  of  tabes 
probable.  This  diagnosis  received  support  also  from  the  extreme 
hypertension  due  to  arteriospasm  accompanying  the  attack.  I 
suggested  that  lumbar  puncture  be  done  and  the  spinal  fluid  exam- 
ined. On  the  same  day  Dr.  Kingsley  withdrew  10  c  c.  of  cerebro- 
spinal fluid.  It  was  under  a  pressure  of  from  150  to  200  mm.. 
H20,  clear  and  colorless.  There  were  50  cells  per  cubic  millimeter, 
all  lymphocytes.  The  fluid  contained  both  globulin  and  serum 
albumin.  These  tests  demonstrated  the  existence  of  either  a  luetic 
or  a  metaluetic  lesion  of  the  central  nervous  system. 

Sensation  was  carefully  tested  on  October  15,  when  the  left  lower 
extremity  was  found  to  be  almost  wholly  analgesic  and  the  right  also, 
except  for  a  portion  on  the  lateral  surface  of  the  limb.  There  was 
also  analgesia  in  the  domain  of  the  second  thoracic  of  each  arm. 
A  patch  of  analgesia  was  found  upon  the  right  side  of  the  scalp 
(Figs.  1  and  2).  Touch  was  nowhere  impaired  and  thermal  sensa- 
tion was  not  markedly  involved. 

On  October  20  the  eyes  were  thoroughly  examined  by  Dr.  Bordley. 
One  of  them  had  been  dilated  with  atropine.  The  other  showed 
extreme  myosis  and  did  not  react  to  light  and  only  imperfectly  to 
accommodation.  Stelwag's  and  von  Graefe's  signs  were  positive. 
Convergence  was  poor.  There  was  advanced  arteriosclerosis  of  the 
retinal  vessels,  some  of  the  smaller  arteries  being  almost  completely 
obliterated.  The  veins  were  markedly  indented  by  the  arteries,  and 
in  places  tortuous.  There  was  no  change  in  the  papillae  nervi  optici 
except  hyperemia  from  obstruction  to  the  venous  circulation. 


634  barker:  gastric  crises  of  tabes 

The  Wassermann  reaction  done  by  Dr.  Guthrie  was  found  to  be 
negative. 

Examination  of  the  urine:  Normal  in  color;  specific  gravity,  1010 
to  1018;  acid;  no  sugar;  no  albumin.  Microscopic  examination 
was  negative.    Acetone  was  present  only  during  the  vomiting. 

The  course  of  the  blood  pressure  is  shown  in  the  accompanying 
chart  (Fig.  3). 


Fig.  I. — Analgesia  at  the  first  Fig.  2. — Analgesia  at  the  second 

examination.  examination. 


The  patient's  pain  was  relieved  by  morphine.  As  soon  as  the 
vomiting  stopped  she  was  given  small  quantities  of  milk  every  two 
hours.  During  the  next  five  days  she  had  only  two  attacks  of 
nausea  and  vomiting.  She  began  to  have  a  good  appetite  and  to 
feel  very  much  better.  The  blood  pressure  (maximal)  varied 
between  175  and  215  mm.  Hg.  until  the  18th.  On  the  19th  the 
maximal  pressure  was  found  to  be  only  120  mm.  Hg.,  and  since 
then  it  has  varied  between  110  and  125  mm.  Hg. 

Since  the  fundamental  studies  of  Fournier  upon  the  phenomena 
of  early  tabes  the  pains  in  the  upper  abdomen  in  this  disease  have 


barkek:  gastric  crises  of  tabes 


635 


been  classified  under  four  main  headings:  (1)  Crises  in  which  there 
is  vomiting  alone;  (2)  crises  in  which  there  is  pain  alone;  (3)  the 
grande  crise  gastrique,  in  which  the  phenomena  are  complicated 
and  violent,  and  include  extreme  pain,  vomiting,  and  retching,  with 
severe  general  symptoms;  and  (4)  crises  in  which  the  appetite  is 
entirely  lost,  though  other  signs  may  be  absent. 


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Fig.  3. — The  course  of  the  blood  pressure. 


The  patient  whose  history  has  been  given  evidently  suffered  from 
crises  of  the  third  type,  and  it  is  to  this  form  of  gastric  crises  in  tabes 
that  I  desire  to  refer,  making  it,  however,  distinctly  understood 
that  in  the  other  three  types  of  crises  many  of  the  features  of  Type  3 
may  be  lacking. 

In  the  crises  from  which  this  woman  suffered  the  pain  was  situated 
in  the  upper  abdomen  and  radiated  into  the  back.  The  pain  was 
accompanied  by  paroxysmal  arteriospasm,  with  great  elevation  of 
the  maximal  arterial  pressure.  That  the  hypertension  depended 
upon  the  arteriospasm  was  evident  from  the  effect  of  amyl  nitrite, 


636 


barker:  gastric  crises  of  tabes 


which  reduced  the  maximal  pressure  promptly  to  90  mm.  Hg., 
though  as  soon  as  the  effects  of  the  nitrite  had  worn  off  the  hyper- 
tension reappeared.  The  marked  oscillations  in  the  maximal 
pressure  during  the  crises  are  evident  in  the  blood  pressure  chart 
(Fig.  3).  It  was  only  after  the  pressure  returned  to  normal  and 
remained  on  the  normal  level  that  the  symptoms  disappeared.  A 
study  of  similar  cases  in  the  literature  indicates  that  partial  falls 
of  the  pressure  are  significant  only  of  remissions  in  the  crises,  not 
of  termination.  The  abrupt  terminal  fall  in  pressure  is  striking, 
and  the  maintenance  of  a  tolerably  steady  pressure  at  the  low  level 
after  the  period  of  hypertension  seems  to  me  most  interesting. 

There  are  at  least  three  conditions  in  which  attacks  of  severe 
abdominal  pain  with  paroxysmal  hypertension  occur:  (1)  The 
gastric  crises  referred  to  above;  (2)  lead  colic;  and  (3)  the  angina 
abdominis  of  arteriosclerosis.  A  number  of  cases  of  all  three  condi- 
tions have  been  collected  and  carefully  analyzed  by  J.  Pal.1  In  these 
cases,  besides  the  pain  and  hypertension,  the  attacks  presented  several 
other  characteristic  features,  including  (1)  constipation,  (2)  boat- 
shaped  retraction  of  the  abdomen,  (3)  in  some  cases  meteorism,  and 
(4)  in  many  instances  segmental  sensory  disturbances  (usually 
hyperesthesia  or  hyperalgesia)  in  the  root  domains  of  the  lower 
thoracic  and  upper  lumbar  spinal  nerves. 

There  has  been  much  dispute  as  to  the  origin  of  the  pain  in  these 
cases  and  its  relation  to  the  hypertension.  Some  authors  assume 
a  primary  neuralgic  pain  with  secondary  hypertension  due  to  the 
pain ;  others,  with  Pal,  regard  the  hypertension  as  the  result  of  vaso- 
constriction of  the  small  arteries  of  the  stomach  and  intestines,  and 
look  upon  the  pain  as  due  to  stretching  of  nerves  in  the  arterial 
sheaths  of  the  same  arteries  proximal  to  their  constricted  portions, 
assuming  that  in  these  proximal  regions  of  the  gastro-intestinal 
arteries  the  arterial  wall  is  distended  and  under  very  high  pressure. 
The  researches  of  experimental  physiologists  and  surgeons  tend  to 
confirm  the  view  that  the  only  pain  nerves  in  the  stomach  and  intes- 
tines are  those  in  the  walls  of  the  bloodvessels.  It  has  long  been 
known  that  the  visceral  peritoneum  (not  the  parietal)  is  insensitive, 
and  there  is  evidence  to  prove  that  even  violent  contusion  of  the 
intestine  or  stomach  (such  as  crushing  with  Dupuytren's  scissors) 
causes  no  pain. 

In  the  gastric  crises  of  tabes  it  is  assumed  that  irritation  in  either 
the  posterior  roots  of  the  spinal  nerves  or  their  continuations  within 
the  cord  leads  to  a  reflex  vasomotor  constriction  which  is  most  ex- 
treme in  the  splanchnic  domain.  If  this  explanation  is  correct 
we  must  assume  that  we  have  to  deal  in  tabes  at  times  with  elective 
stimulation  of  posterior  root  fibers,  for  when  tabetics  suffer  from 
lancinating  pains  in  the  lower  extremities  the  blood  pressure  is 


l  Gefasskrisen,  Leipzig,  1905,  pp.  1  to  275. 


barker:  gastric  crises  of  tabes 


637 


usually  low  and  we  must  assume  in  such  cases  a  reflex  vasodilatation. 
In  the  gastric  crises  of  tabes  there  is  paroxysmal  arteriospasm  and 
hypertension,  and  we  must  assume  here  a  reflex  vasoconstriction. 
It  is  interesting  that  lancinating  pains  and  gastric  crises  rarely  occur 
together  in  tabes,  though  their  alternation  is  not  uncommon.  This 
disparity  in  the  symptomatology  of  incipient  tabes,  pointing  to  an 
elective  stimulation  of  the  posterior  root  fibers  or  their  intramedul- 
lary continuations,  has  led  me  to  think  of  our  embryological  knowl- 
edge of  the  posterior  roots.  Since  the  studies  of  Flechsig  and,  later, 
of  Trepinski  we  have  known  that  the  fibers  of  the  dorsal  funiculi 
do  not  become  medullated  all  at  once.  Definite  groups  of  these 
fibers  receive  their  myelin  at  very  different  periods,  and  Flechsig 
has  subdivided  the  fibers  into  four  distinct  embryological  systems.2 
The  fibers  of  these  different  systems  have  different  terminations  in 
the  cord  and  in  all  probability  subserve  different  functions.  It 
has  also  been  shown,  through  the  microscopic  study  of  the  spinal 
cord  in  cases  of  tabes,  that  a  very  distinct  parallelism  occurs  between 
the  areas  degenerated  in  this  disease  and  the  embryological  member- 
ment  in  the  fcetal  cords.  Furthermore,  it  has  been  shown  that  in 
tabes  the  sequence  in  which  the  several  systems  suffer  may  vary. 
It  seems  to  me  highly  desirable,  therefore,  that  cases  of  incipient 
tabes  carefully  studied  clinically,  which,  through  some  intercurrent 
disease,  come  to  autopsy  before  degeneration  is  advanced,  should  be 
most  closely  investigated  microscopically.  In  this  way  we  may 
hope  for  gradual  enlightenment  concerning  the  functions  of  the 
different  systems  of  fibers  contained  within  the  dorsal  roots  of  the 
spinal  nerves. 

The  explanation  of  the  phenomena  other  than  the  pain  and  hyper- 
tension in  the  gastric  crises  of  tabes  has  also  been  attempted  by 
various  writers.  Though  the  explanations  thus  far  offered  leave 
still  much  to  be  desired,  opinion  at  present  leans  to  the  view  that  the 
vomiting  is  a  reflex  vagal  phenomenon;  that  the  constipation  is  due 
to  paralysis  of  the  intestine  from  ischemia  due  to  the  vasocon- 
striction; that  the  boat-shaped  retraction  of  the  abdomen  is  to  be 
regarded  as  a  reflex  through  the  motor  spinal  nerves  of  the  corre- 
sponding segments;  and  that  the  segmental  hyperesthesia  is  to  be 
thought  of  as  due  to  "  referred  sensation"  in  the  sense  of  Head, 
resulting  from  the  violent  impulses  passing  along  the  stretched 
perivascular  sympathetic  nerves  and  reaching  the  cell  bodies  (within 
the  spinal  ganglia)  of  the  neurones  of  the  lower  thoracic  and  upper 
lumbar  dorsal  nerve-roots. 

Since  in  arteriosclerosis  attacks  of  angina  abdominis  closely 
resembling  those  of  the  grand  gastric  crises  of  tabes  occur,  it  might 
be  thought  that  the  attacks  in  the  patient  reported  above  were  due 
to  the  arteriosclerosis  rather  than  to  tabes,  but,  though  the  knee- 

2  L.  F.  Barker,  The  Nervous  System,  New  York,  1899,  p.  424  et  seq. 


638 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


kicks  were  lively,  the  pupils  were  very  sluggish  to  light  and,  above 
all,  the  lymphocyte  count  in  the  cerebrospinal  fluid  was  markedly 
increased,  and  the  protein  content  of  that  fluid  indicated  the  existence 
of  a  parasyphilitic  disease.  Moreover,  vomiting  appears  to  be  less 
common  in  the  angina  abdominis  of  arteriosclerosis  than  in  the 
gastric  crises  of  tabes. 

To  one  other  point  attention  should  be  called,  namely,  the  wide 
distribution  of  the  analgesia  and  the  great  differences  in  this  distri- 
bution at  different  periods.  In  the  absence  of  disturbances  of  tactile 
and  thermal  sensation  such  an  extensive  analgesia  could  scarcely 
be  due  to  the  tabes.  It  seems  much  more  probable  that  this  anal- 
gesia and  the  globus  of  which  the  patient  complained  are  hysterical 
manifestations  complicating  the  more  serious  malady. 

Should  these  severe  crises  continue  in  this  patient,  we  shall  con- 
sider the  advisability  of  cutting  intradurally  the  seventh,  eighth,  and 
ninth  dorsal  nerve  roots  on  both  sides  of  the  body  (Foerster's  opera- 
tion). In  Kiittner's  case  and  in  that  reported  by  Bruns  and  Sauer- 
bruch3  the  results  were  eminently  satisfactory. 


A  STUDY  OF  FIVE  HUNDRED  AND  FIFTY  CASES  OF 
TYPHOID  FEVER  IN  CHILDREN. 

By  Samuel  S.  Adams,  A.M.,  M.D., 

PROFESSOR    OF  THE    THEORY  AND    PRACTICE    OF    MEDICINE  AND   OF    DISEASES    OF  CHILDREN 
IN   THE    GEORGETOWN   UNIVERSITY,   WASHINGTON,    D.  C. 

In  November,  1903,  I  read  a  paper  before  the  Medical  and 
Chirurgical  Faculty  of  Maryland,  the  subject  being  a  study  of  337 
cases  of  enteric  fever  in  children.  Now  it  is  my  intention  to  present 
a  further  study,  by  analyzing  213  additional  cases,  which  have  been 
treated  during  the  half  decade  ended  December,  1908. 

In  this  study  of  550  cases  of  typhoid  fever  treated  in  the  Children's 
Hospital,  District  of  Columbia,  many  obstacles,  some  insurmount- 
able, were  encountered.  The  period  over  which  the  investigation 
extends  has  been  divided  into  three  and  a  half  decades,  which  seem 
to  conform  to  the  changes  of  ideas  respecting  this  particular  disease, 
embracing  the  years  1872  to  1908,  inclusive.  During  the  first 
decade  all  cases  of  typhomalarial  fever  were  excluded,  because  this 
was  then  thought  to  be  a  distinct  disease  possessing  only  a  few 
symptoms  similar  to  those  found  in  enteric  fever.  During  the 
second  decade  these  were  included,  because,  by  common  consent, 
all  typhomalarial  cases  were  then  recognized  as  enteric.    In  the 

3  Operativer  Behandlung  gastrischer  Krisen,  Foersterscher  Operation,  Mittheil.  a.  d. 
Grenzgeb.  d.  Med.  u.  Chir.,  1909,  xxi,  173  to  178. 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


639 


third  decade,  cases  of  mixed  infection  which,  in  their  clinical  and 
pathological  phenomena  were  identical  with  the  typhomalarial 
diseases  of  the  previous  decades,  have  been  incorporated.  There 
might  have  been  justification  in  swelling  the  number  by  including 
the  many  cases  recorded  in  the  first  fifteen  years  under  the  headings 
infantile  remittent,  remittent  continued,  and  irregular  fevers,  because 
I  was  then  serving  as  an  assistant  physician  in  the  hospital,  and,  in 
the  light  of  our  present  knowledge,  I  now  believe  that  such  cases 
were  genuine  enteric  fever.  In  spite  of  the  fact  that  continuous 
connection  with  the  hospital  since  1876  has  given  me  ample  oppor- 
tunities for  careful  study  of  those  cases,  I  do  not  feel  justified  in 
changing  the  diagnosis  made  by  my  predecessors. 

In  the  earlier  years  of  practice,  I  was  among  the  few  who  did  not 
believe  in  the  immunity  of  infants  and  young  children  to  enteric 
fever.  When  some  advanced  the  opinion  (from  which  they  have 
fortunately  receded)  that  infants  rarely,  if  ever,  had  enteric  fever, 
and  supported  it  by  their  failure  to  find  the  intestinal  lesions  of  the 
disease  in  a  large  number  of  necropsies,  I  strenuously  contended 
that  infants  and  young  children  had  a  disease,  which  clinically  was 
the  analogue  of  enteric  fever  in  the  adult,  and  shortly  thereafter 
presented  to  our  local  society  the  intestine  from  an  infant  showing 
lesions  identical  with  those  found  in  adults  who  had  died  of  enteric 
fever.  During  the  past  ten  years,  I  have  seen  an  epidemic  in  one 
of  our  institutions,  which  spent  its  force  upon  infants  under  one 
year  of  age ;  and  during  the  last  five  years  have  seen,  in  private  prac- 
tice, at  least  a  dozen  typical  cases,  several  of  which  were  used  to 
illustrate  a  lecture  on  typhoid  fever  in  infants,  delivered  at  the 
Harvard  Medical  School  in  1907.  The  clinical  phenomena,  includ- 
ing direct  infection,  were  those  of  enteric  fever,  and  I  presented  a 
specimen  from  one  of  the  cases  which  showed  ulceration  and  per- 
foration of  the  ileum.  Of  late  all  doubts  on  this  point  have  been 
dispelled  by  pediatrists  generally.  The  acceptance  of  the  theory 
of  immunity  unquestionably  obscured  the  diagnosis  in  a  number 
of  cases,  which  might  otherwise  have  added  to  the  interest  of  this 
paper.  Enteric  fever  in  the  child  differs  in  degree  only  from  that 
in  the  adult.  While  the  clinical  phenoirena  differ  somewhat,  the 
structural  changes  are  identical,  regardless  of  age. 

There  has  been  an  annual  increase  in  the  number  of  cases  treated 
in  the  hospital  relative  to  the  whole  number  of  patients  admitted. 
This  has  been  about  uniform,  except  in  two  instances,  when  it  was 
much  greater'  owing  to  the  prevalence  of  enteric  fever,  in  epidemic 
form,  in  the  city. 

Season.  Of  the  550  cases,  420  (76.54  per  cent.)  were  admitted 
during  July,  August,  September,  and  October. 


640 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


Table  Showing  Cases  Admitted  by  Months. 


Cases.  Cases. 

January   18       July   78 

February   11       August   153 

March   6       September   119 

April   11        October   70 

May   6       November  .    38 

June   21       December   18 


Sex.  Two  hundred  and  ninety-six  boys  and  254  girls  were 
treated,  this  being  about  the  proportion  in  adults  admitted  to 
general  hospitals. 

Age.  At  the  organization  of  the  hospital  the  maximum  age  of 
children  admitted  was  fifteen  years  and  the  minimum  two  years. 
The  maximum  was  gradually  lowered  until  in  1888  it  was  fixed  at 
twelve  years,  which  accounts  for  the  small  number  between  twelve 
and  fifteen  years.  There  is  a  decided  increase  in  the  number 
admitted  after  the  fourth  year,  which  may  be  due  to  increased  sus- 
ceptibility at  the  beginning  of  school-life. 

Table  Showing  Ages. 

Cases.  Cases. 

One  year  1  Nine  years   61 

Two  years   22  Ten  years   72 

Three  years   29  Eleven  years   77 

Four  years   27  Twelve  years   33 

Five  years   50  Thirteen  years  3 

Six  years   50  Fourteen  years  3 

Seven  years   65  Fifteen  years    ......  5 

Eight  years   49  Not  given  2 

Mode  of  Conveyance.  It  is  a  singular  coincidence  that  the 
first  case  of  enteric  fever  treated  was  attributed  to  the  eating  of 
oysters.  This  was  in  1872,  and  yet  it  was  quite  twenty-five  years 
thereafter  that  the  oyster  was  recognized  as  a  carrier  of  typhoid 
bacilli.  Four  cases  were  attributed  to  polluted  milk,  25  to  water, 
and  43  to  contagion.  In  478  cases  no  record  was  made  as  to  the 
mode  of  conveyance.  In  the  43  cases  attributed  to  contagion  there 
was  in  every  case  evidence  of  direct  exposure,  in  many  instances 
several  cases  having  occurred  in  the  same  family.  The  proof  is 
positive  in  several  cases  in  which  water  is  mentioned  as  the  medium. 
These  cases  came  from  a  locality  where  enteric  fever  was  epidemic 
at  the  time  of  their  admission.  The  children,  as  well  as  many, 
if  not  all,  of  those  affected,  had  drunk  the  water  from  a  neighboring 
well,  which,  upon  examination,  was  found  to  contain  the  colon  and 
other  bacilli,  together  with  fecal  matter. 

Morbid  Anatomy.  In  43  cases  the  necropsy  revealed  the 
characteristic  lesions  and  in  addition  structural  changes  in  the  other 
organs.    In  22  necropsies  were  not  permitted. 

Perforation  was  found  in  17  cases,  all  being  of  the  ileum.  In  1  case 
three  perforations  were  found,  in  2  cases  two,  and  in  the  remainder 
but  one. 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


641 


Hemorrhage.  Twenty-eight  deaths  resulted  from  hemorrhage, 
but  in  no  instance  could  the  bleeding  vessel  be  found. 

Spleen.  The  spleen  was  almost  invariably  enlarged  in  the  fatal 
cases. 

Liver.  No  pathological  condition  was  found  in  the  liver.  Abscess 
of  the  gall-bladder  was  found  in  one  of  the  recent  cases. 

Kidney.  Acute  nephritis  was  present  in  8  cases,  the  condition 
having  been  recognized  before  death. 

The  respiratory  organs  were  affected  in  7  cases,  the  circulatory 
in  3,  the  brain  in  3,  the  peritoneum  in  2,  and  the  bladder  in  1. 

Mode  of  Onset.  The  disease  was  recorded  as  beginning 
insiduously  in  361  cases,  with  diarrhoea  in  17,  malaise  in  14,  chills 
in  66,  suddenly  in  81,  delirium  in  7,  cough  in  5,  vomiting  in  8, 
headache  in  6,  synovitis,  stupor,  nausea,  and  tonsillitis  in  2  each, 
and  with  coryza,  adenitis,  arthritis,  erythema,  sweats,  and  insomnia 
in  1  each;  and  the  onset  is  not  mentioned  in  24  cases. 

Symptoms.  Temperature.  The  course  of  the  fever  in  children  is 
usually  of  the  remittent  type,  ranging  from  103°  F.  to  105°  F.,  and 
terminates  by  lysis.  In  this  series  the  fever  in  279  was  remittent,  in 
24  intermittent,  in  3  irregular,  and  in  2  atypical.  The  fever  ter- 
minated by  lysis  in  241  and  by  crisis  in  19.  Posttyphoidal  rise  was 
noted  in  4  cases  and  was  due  to  some  error  in  management.  There 
were  11  septic  cases  that  were  most  pronounced;  4  of  these  died. 
Recrudescence  was  noted  in  a  very  small  proportion  of  cases.  Chills 
were  recorded  in  73  cases,  13  being  at  the  outset. 

Rose-spots  are  not  as  frequent  in  children  as  in  adults.  They 
were  present  in  133  cases  only,  but,  as  about  20  per  cent,  of  the  cases 
were  negroes,  the  percentage  is  not  accurate.  Sudamina  and  miliaria 
are  more  common  in  the  negro  child. 

Sweats.  More  or  less  sweating  at  the  height  of  the  fever  is  not 
uncommon,  and  in  this  series  it  was  so  profuse  in  10  cases  as  to 
classify  them  under  the  sudoral  variety. 

Bed  sores  so  seldom  occur  in  children  that  it  was  not  regarded 
as  important  to  consider  them.    Furunculosis  occurred  seven  times. 

Circulatory  System.  The  changes  presented  by  the  blood  differ 
slightly  from  those  found  in  the  adult.  There  was  1  case  of  peri- 
carditis and  endocarditis  and  one  of  endocarditis.  One  case  of 
phlebitis  of  the  femoral  vein  was  noted. 

Digestive  System.  Five  cases  of  ulceration  of  the  mouth,  one 
being  gangrenous,  were  recorded.  One  case  of  esophagismus  of 
exceeding  interest  was  found.  The  boy  was  seven  years  of  age 
and  had  a  typical,  moderately  severe,  attack  of  enteric  fever.  At 
the  height  of  the  disease,  in  attempting  to  take  drink  or  nourish- 
ment/a tonic  spasm  of  the  oesophagus  would  occur.  This  necessitated 
rectal  feeding.  After  a  long  convalescence  the  patient  recovered. 
Adenitis  and  parotitis  occurred  in  21  cases,  most  of  which  sup- 
purated.   Pharyngeal  symptoms  were  recorded  in  8  cases.  Diar- 


642 


ADAMS:  TYPHOID  FEVER  IN  CHILDREN 


rhoea  was  of  infrequent  occurrence  after  the  first  stage,  and  when 
present  was  usually  controlled  by  change  of  food.  Hemorrhage 
occurred  in  54  cases  (9.8  per  cent.);  27  (50  per  cent.)  of  which 
died.  In  1  case  there  were  three  profuse  hemorrhages  and  the  child 
recovered,  while  in  the  27  fatal  cases,  but  one  hemorrhage  was 
recorded.  Meteorism  and  tympanites  were  noted  in  14  cases.  In 
6  the  distension  was  unusually  great  and  caused  intense  suffering. 
Abdominal  tenderness  and  gurgling  were  not  as  frequently  observed 
as  in  the  ordinary  diarrhoea  of  children.  Indeed,  I  regard  the 
gurgling  and  tenderness  in  the  right  iliac  fossa  as  of  little  practical 
clinical  value.  Of  the  550  cases  there  were  17  (3  per  cent.)  with 
perforation,  all  of  which  were  fatal.  The  diagnosis  of  per- 
foration was  made  in  every  case  within  a  few  hours  after  its 
occurrence.  In  several  cases  an  operation  was  proposed,  but  the 
parents  would  not  permit  it.  In  other  cases  peritonitis  developed 
so  rapidly  that  an  operation  was  not  deemed  advisable.  Three 
children  were  operated  on  when  in  extremis,  and  died  a  few  hours 
thereafter.  Enlargement  of  the  spleen  was  recorded  in  149  cases, 
but  undoubtedly  greater  care  in  case-recording  in  the  earlier 
decades  would  have  increased  the  number.  Epistaxis  was  found 
in  225  cases  (40.9  per  cent.),  in  many  of  which  it  was  troublesome, 
and  in  1  profuse  and  fatal. 

Pulmonary  System.  Bronchitis  was  present  in  31  cases  in  the 
earlier  stages.  Pneumonia  was  noted  in  15  cases,  one  of  which 
proved  fatal. 

Nervous  System.  Delirium.  Children  usually  bear  high  tem- 
peratures much  better  than  adults,  but  our  statistics  show  a  large 
percentage  (56. IS  per  cent.)  of  nervous  perturbations  attributable 
to  the  pyrexia.  The  amount  of  fever  formed  no  index  of  mental 
disturbances. 

Table  Showimg  Tvte  of  the  Delirium. 

Cases. 


Mild   51 

Low,  muttering   155 

Wild   59 

Maniacal   8 

Hysterical   1 

Stupor   12 

Coma   1 


The  distinction  drawn  between  wild  and  maniacal  delirium  is 
arbitrary.  Those  classed  as  wild  were  thoroughly  unaccountable 
and  required  restraint;  while  the  maniacal  had  hallucinations, 
delusions,  and  violent  tendencies.  Convulsions:  In  16  cases 
convulsions  appeared  during  the  fastigium  and  not  at  the  onset, 
as  is  the  case  in  other  infectious  diseases  in  children.  All  of  these 
cases  were  fatal.  Neuritis:  Local  neuritis  during  convalescence 
was  observed  in  5  cases,  all  of  which  recovered.  Hemiplegia  with 
a  fatal  termination  occurred  once.    Post-typhoidal  insanity  was 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


643 


observed  during  convalescence  in  9  cases,  which  had  run  a  mild 
course  without  delirium.  They  were  all  due  to  faulty  nutrition  and 
promptly  recovered  with  improvement  in  general  health.  I  have 
reported  4  of  these  cases.1 

Ear.  Otitis  media  supervened  in  15  cases  (2.7  per  cent.).  Sup- 
puration was  profuse,  but  the  disease  only  invaded  the  mastoid  cells 
in  1  case.  Deafness,  sometimes  profound,  was  frequently  observed 
during  the  height  of  the  disease,  but  always  disappeared  with  the 
subsidence  of  the  fever. 

Renal  System.  Retention  of  urine  is  not  often  met  with  in  children, 
but  it  was  mentioned  in  2  of  these  cases.  The  diazo  reaction  was 
applied  in  182  cases,  with  73  (40.1  per  cent.)  positive.  [The  test  is 
made  when  the  child  is  admitted,  and  daily  thereafter,  but  the  posi- 
tive reaction  is  often  delayed  as  late  as  the  third  week.]  This  test 
was  abandoned  several  years  ago.  Albuminuria  during  the  febrile 
stage  occurred  in  40  cases  (7.2  per  cent.),  but  usually  disappeared 
during  convalescence.  Acute  nephritis  was  noted  in  15  cases  (2.7 
per  cent.),  5  being  fatal. 

Postenteric  pyemia  infrequently  manifests  itself  by  abscesses. 
At  one  time  there  were  3  cases  of  perirectal  abscess  in  the  hospital. 
No  case  of  multiple  abscesses  was  recorded,  but  a  boil  on  the  head, 
buttocks,  thigh,  or  back  was  not  uncommon. 

Association  with  Other  Diseases.  In  an  institution  in 
which  tuberculous  diseases  prevail  so  extensively,  it  is  somewhat 
surprising  not  to  find  acute  miliary  tuberculosis  associated  with, 
or  directly  following,  an  attack  of  enteric  fever  much  earlier  than 
1909.  Since  then  pulmonary  tuberculosis  has  fatally  attacked  5 
convalescents,  which  are  included  in  this  series.  Scarlatina,  measles, 
malaria,  and  pseudo-membranous  pharyngitis  and  laryngitis  also 
complicated  the  cases.  Cancrum  oris  occurred  in  4  cases,  all  being 
fatal. 

Varieties  of  Fever.  Typhoid  fever  in  children  presents  such 
various  modifications  in  its  complex  symptomatology  that  its  classi- 
fication as  to  degree  depends  entirely  upon  the  observer.  The 
course  might  be  considered  mild,  and  yet  hemorrhage  or  perfora- 
tion would  cause  an  unexpected  fatal  termination;  on  the  other  hand, 
a  case  may  be  grave  from  the  initial  stage,  and  when  least  expected 
a  rapid  return  to  health  may  take  place.  It  has  been  our  custom  to 
classify  as  follows: 

Cases. 


Mild   264 

Moderately  severe   132 

Severe   142 

Irregular   2 

Sudoral2   10 


550 

1  Trans.  Amer.  Pediatric  Society,  viii,  177. 

2  The  term  sudoral  is  used  to  define  a  condition  in  which  there  is  profuse  sweating  during 
the  fastigium. 


644  ADAMS :  TYPHOID  FEVER  IN  CHILDREN 

Relapses.  There  were  48  relapses  (8.7  per  cent.),  4  cases  having 
two  each,  with  1  death.  In  a  case  of  septic  enteric  fever  death 
occurred  during  the  relapse.  My  experience  has  been  that  a  relapse 
is  of  milder  type  and  shorter  duration  than  in  the  adult.  The  re- 
lapses here  noted  are  true  ones,  but  several  spurious  relapses  have 
occurred  which  were  of  slight  significance. 

Diagnosis.  There  have  been  but  few  mistakes  in  diagnosis,  the 
greatest  difficulty  being  to  differentiate  enteric  from  estivo-autumnal 
malarial  fever,  when  the  blood  examination  was  negative.  However, 
observation  and  repeated  blood  examinations  finally  settled  the  ques- 
tion. The  Widal  test  was  applied  in  283  cases  and  gave  positive 
results  in  130  (49  per  cent.)  This  percentage  is  a  trifle  lower  than 
the  results  of  other  observers  and  may  have  been  due  to  imperfect 
methods,  which  were  unavoidable,  before  the  establishment  of  a 
laboratory  in  the  hospital.  During  the  last  five  years  a  positive 
reaction  has  been  obtained  at  some  time  during  the  course  of  most 
cases,  but  in  most  cases  during  convalescence,  and  in  a  few  tests 
have  invariably  been  negative.    No  blood-cultures  have  been  made. 

Mortality.  There  were  65  deaths,  a  rate  of  11.8  per  cent. 
Taking  the  periods  separately,  we  see  the  greatest  reduction  in  the 
last  decade  and  a  half,  which  is  unquestionably  due  to  the  methods 
of  treatment  employed.  It  must  be  stated  that  a  number,  especially 
colored  children,  died  within  forty-eight  hours  after  admission,  and, 
although  they  are  included  in  the  death-list,  yet  they  might,  with 
propriety,  be  excluded,  which  would  reduce  the  mortality  con- 
siderably. 

Mortality. 

Cases.        Deaths.      Per  cent. 


1872-1882    26  8  30.76 

1882-18913    59  12  20.33 

1892-19034    252  28  11.1 

1903-1908    273  17  7.9 


Analysis  of  the  fatal  cases.  There  were  32  boys  and  33  girls, 
whose  ages  ranged  as  follows:  Two  years,  2;  three  years,  3;  four 
years,  4;  five  years,  8;  six  years,  8;  seven  years,  8;  eight  years,  2; 
nine  years,  6;  ten  years,  12;  eleven  years,  11;  twelve  years,  5;  and 
fourteen  years,  2.  One  was  infected  by  oysters,  2  by  milk,  5  by 
contagion,  and  4  by  water.  The  necropsy  was  made  in  40  and 
revealed  the  characteristic  local  and  parenchymatous  lesions.  In 
4  subjects  who  had  died  of  pulmonary  tuberculosis,  the  intestinal 
lesions  had  healed.  The  onset  was  insidious  in  40;  by  gastroenteric 
symptoms  in  8;  by  angina  in  1;  by  chills  in  3,  and  suddenly  in  11. 

3  It  will  be  seen  by  the  table  that  no  cases  are  given  in  1885.  This  omission,  as  well  as 
that  of  1897,  was  owing  to  the  loss  of  records.  In  the  annual  report,  1885,  3  cases  are  re- 
ported, all  of  which  recovered,  which  will  reduce  the  mortality  of  the  second  decade  to  19.35 
per  cent. 

4  In  1897  11  cases  were  treated  and  1  died,  which  will  reduce  the  mortality  in  the  third 
decade  to  9.27  per  cent. 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


645 


There  were  rose  spots  in  9.  The  fever  was  remittent  in  38,  inter- 
mittent in  6,  atypical  in  6,  septic  in  2,  and  not  stated  in  2.  Epis- 
taxis  was  noted  in  32,  chills  in  16,  intestinal  hemorrhage  in  26, 
perforation  in  16,  nephritis  in  11,  convulsions  in  11,  and  pneumonia 
in  6.  The  delirium  was  wild  in  28,  muttering  in  22,  maniacal  in  1. 
In  9  the  spleen  was  enlarged.  Such  complications  as  bronchitis, 
pneumonia,  peritonitis,  cancrum  oris,  aphonia,  gangrenous  stomatitis, 
hemiplegia,  pulmonary  tuberculosis,  mitral  disease,  and  endo- 
carditis, helped  to  swell  the  mortality.  The  variety  of  the  fever 
was  severe  in  59,  moderately  severe  in  5,  and  mild  in  1.  Thirty- 
five  were  treated  by  hydrotherapy;  3  by  antiseptics;  6  by  eliminative 
and  antiseptic  methods;  10  by  antiperiodics;  and  8  by  antipyretics. 
Excessive  diarrhoea  was  treated  six  times;  hemorrhage  fifteen; 
nervousness  four,  and  cardiac  weakness  twenty-seven  times. 

Treatment.  The  general  management  of  the  cases  was  of  the 
same  character  throughout,  but  the  systematic  methods  of  the  trained 
nurse,  which  superseded  the  crude  ones  of  the  unskilled  in  the  first 
decade,  contributed  much  to  the  better  results  obtained  in  the  second 
and  third  periods. 

The  diet  which  was  uniformly  liquid  during  the  first  three  decades, 
consisted  of  milk  and  animal  broths,  except  in  2  cases  in  which  "  pud- 
ding diet"  was  noted.  I  am  not  familiar  with  this  last  named  food 
for  enteric  cases,  nor  was  I  able  to  ascertain  its  full  meaning,  but  I 
suspect  that  the  patients  for  whom  the  pudding  was  ordered  were  in 
the  convalescent  stage. 

In  the  first  decade  there  were  twenty-six  patients  who  were  treated 
as  follows : 


Cold  sponging  .   5 

Antiseptic  treatment   1 

Antiperiodic  treatment  20 

It  will  be  seen  that  20  received  quinine.  During  this  period 
Liebermeister's  treatment  was  in  vogue,  and  I  can  recall  the  large 
doses  of  quinine  given,  which  had  little  effect  upon  the  fever,  but 
often  irritated  the  stomach  and  increased  the  nervous  symptoms. 

In  the  second  decade  59  patients  received  the  following  treatment : 


Cases. 


Cold  sponging   23 

Cold  pack  -  •  .  1 

Antiseptic  treatment   5 

Eliminative  and  antiseptic  treatment   4 

Nervous  symptoms  treated   32 

Antiperiodic  treatment   30 

Antipyretic  treatment   16 


Daylight  was  beginning  to  dawn  on  the  treatment,  and  the  benefi- 
cial effects  of  reducing  high  temperature  by  external  applications  of 
cold  were  realized.    This  change  of  treatment  was  not  well  estab- 


646 


ADAMS:  TYPHOID  FEVER  IN  CHILDREN" 


lished  when  that  pernicious  class  of  drugs,  the  so-called  antipyretics, 
was  introduced.  Antipyrin  was  administered  in  16  cases,  4  of  which 
died.  I  remember  with  what  pride  we  gave  the  synthetical  prepara- 
tions to  demonstrate  their  power  of  quickly  reducing  high  tempera- 
tures. It  was  quite  two  years  before  we  realized  that,  while  the 
temperature  was  being  so  beautifully  lowered,  the  necessity  for 
stimulation  increased. 

Quinine  was  now  given  to  50.8  per  cent,  of  the  cases  and  un- 
doubtedly played  its  part  in  augmenting  the  number  requiring 
stimulation. 

In  the  third  decade  the  252  cases  were  treated  as  follows : 

Cases. 


Hydrotherapy   213 

Antiseptic  treatment   33 

Diarrhoea   4 

Hemorrhage   1 

Heart  stimulants                                                                                         .  31 

Nervous  symptoms   1 

Antiperiodic  treatment   27 

Antipyretics  1 


In  this  decade  the  treatment  by  the  various  intestinal  antiseptics 
was  introduced,  but,  after  a  fair  trial,  they  were  discontinued  in 
my  service,  because  I  was  not  convinced  that  any  benefit  resulted 
from  their  administration. 

Twenty-seven  received  quinine,  because  of  mixed  infection,  but 
only  4  were  given  antipyretics;  phenacetin  was  given  to  them  to 
allay  nervous  manifestations  and  not  to  reduce  temperature.  Of 
252  cases,  213  were  treated  by  hydrotherapy.  Under  this  head  are 
included  cold  sponging,  the  cold  pack,  and  tubbing  after  the  method 
of  Brand.  The  regular  treatment  recorded  in  the  tables  means  one  or 
all  of  the  three  methods,  according  to  the  indications  in  each  case. 
About  the  same  number  as  in  the  previous  decade  received  stimu- 
lants, but  for  a  different  purpose.  While  in  the  second  decade  such 
drugs  were  necessitated  by  the  cardiac  depression  from  the  coal-tar 
derivatives,  now  they  were  given  as  routine  treatment  in  carrying 
out  the  Brand  method. 

In  considering  the  results  obtained  in  this  one  hospital  during 
the  last  decade,  it  may  not  be  wise  to  lay  too  much  stress  upon 
figures.  The  reduction  in  death-rate  may  not  be  due  to  the  treat- 
ment, but  by  comparison  with  the  mortality  in  preceding  periods 
under  different  methods  it  emphasizes  the  following  facts: 

From  1892,  the  beginning  of  the  third  decade,  to  1898,  inclusive, 
the  treatment  followed  was  hydrotherapy,  antiseptic,  and  antiperiodic. 
During  this  time  88  cases  were  treated,  10  of  which  died,  giving  a 
mortality  of  11.36  per  cent.  At  the  beginning  of  1899  the  purely 
hydrotherapeutic  treatment  was  begun  and  has  been  strictly  followed 
throughout  the  remainder  of  the  decade,  with  the  result  that  of  the 
164  cases  then  treated  18  died,  giving  a  death  rate  of  10.97  per  cent. 


ADAMS :  TYPHOID  FEVER  IN  CHILDREN 


647 


Four  cases  of  the  last  series  died  of  pulmonary  tuberculosis  either 
during  or  directly  following  a  typical  course  of  enteric  fever.  We 
may  rightly  exclude  them  from  our  mortality  list — when  the  death 
rate  will  be  8.54  per  cent. 

Some  slight  changes  in  treatment  have  been  instituted  during  the 
last  half  decade.  The  diet  was  augmented  in  nutritive  value  by 
the  addition  of  cereals,  eggs,  and  bread  to  the  prescribed  routine 
of  milk  and  broths.  The  patient's  ability  to  digest  such  "soft  food" 
was  carefully  watched  and  only  two  or  three  instances  were  recorded 
in  which  the  semi-solid  food  had  to  be  discontinued.  I  was  rather 
skeptical  at  first  as  to  the  good  results  from  giving  semi-solid  food 
to  typhoid-fever  patients,  but  I  must  confess  to  a  conversion  to  the 
method  so  well  portrayed  by  Shattuck.  Realizing  that  diarrhoea 
is  the  exception  in  the  child  with  typhoid  fever,  one  can  safely  venture 
the  use  of  liberal  feeding.  While  an  occasional  case  may  not  tolerate 
anything  but  liquid  food,  the  majority  will  not  only  relish,  but  will 
digest  and  assimilate  soft  toast,  cereals,  and  soft  boiled  eggs.  By 
adopting  this  method,  most  of  the  heart-rending  scenes  of  the  sick- 
room will  be  avoided.  The  otherwise  patient  child  no  longer  begs 
and  cries  for  "something  to  eat;"  there  is  no  longer  progressive 
emaciation  until  the  little  skeleton  is  covered  by  loose  skin  hanging 
in  folds:  relapses  become  less  frequent;  convalescence  is  shortened; 
and  complete  recovery  replaces  prolonged  invalidism. 

Our  ideas  on  the  Brand  method  have  changed  materially  in  that  it 
was  only  used  in  three  cases  during  this  last  period.  Its  beneficial 
effects  have  been  demonstrated,  but  children  do  not  require  such 
heroic  treatment;  the  sponge  bath  is  quite  as  effective  in  reducing 
temperature,  in  allaying  nervous  perturbations,  and  in  stimulating 
the  activity  of  the  emunctories.  Intestinal  irrigation  was  recently 
tried  in  a  few  cases,  but  its  beneficial  effect  is  not  yet  evident. 

The  table  shows  the  methods  of  treatment: 

Cases. 


Regular   16.5 

Brand   3 

Quinine   22 

Irrigation   24 

Antiseptic   15 

Eliminative   3 


In  concluding,  I  desire  to  state  that  the  cases  were  culled  and  the 
charts  prepared  from  many  imperfectly  kept  records,  by  the  assi- 
duous labors  of  Doctors  Grasty,  Turner,  Riley  and  Smith  in  1903, 
and  by  Doctors  Ong,  Titus,  McLaughlin  and  Durney  in  1909. 
To  all  of  these  I  acknowledge  my  indebtedness. 


648 


ELLIOTT:  ARTERIAL  HYPERTENSION 


ARTERIAL  HYPERTENSION. 

By  Arthur  R.  Elliott,  M.D., 

PROFESSOR  OF  MEDICINE  IN  THE  POSTGRADUATE  MEDICAL  SCHOOL,  CHICAGO. 

Abnormally  high  blood  pressure,  if  once  permanently  established, 
is  a  condition  of  much  significance,  as  it  constitutes  a  grave  depar- 
ture from  the  physiological  norm  and  entails  certain  structural 
and  degenerative  secondary  effects  in  the  arteries  and  heart  of  the 
most  profound  character.  The  mere  fact  of  blood  pressure  being 
habitually  raised  above  normal,  even  to  a  considerable  extent  above 
normal,  does  not  seem  necessarily  to  circumscribe  the  individual's 
activities,  nor  is  it  always  accompanied  by  noteworthy  subjective 
discomfort.  The  change  to  high  levels  is  ordinarily  a  very  gradual 
affair,  the  tissues  progressively  accustom  themselves  to  the  new 
standards  of  pressure,  and  the  economy  may  not  be  disturbed.  We 
consequently  often  find  individuals  with  systolic  readings  over  200 
mm.  Hg.  actively  engaged  in  business  and  professional  affairs, 
unconscious  of  any  disturbance  of  health.  Slowly  but  surely,  never- 
theless, the  excessive  mechanical  strain  to  which  their  circulatory 
organs  is  subjected  begets  serious  degenerative  alterations,  and 
finally  if  the  process  be  not  stayed  the  whole  apparatus  of  the  cir- 
culation will  one  day  fall  to  pieces  like  the  "Deacon's  one  hoss  shay." 
Meanwhile  no  symptoms  of  alarming  nature  may  arise  until  a 
sudden  cardiac  failure  or  an  apoplexy  tragically  reveals  the  true 
state  of  affairs.  Recently  I  was  consulted  by  an  active  business 
man  who  for  several  weeks  had  unsuccessfully  treated  a  cough, 
which  was  attended  by  asthmatic  symptoms.  He  was  found  to 
have  a  blood  pressure  of  245  mm.  with  a  pulse  of  124,  gallop  rhythm, 
jugular  pulse,  pulmonary  congestion,  hepatic  hyperemia,  and 
albuminuria.  In  many  a  man  above  sixty  we  find  a  basic  systolic 
murmur  and  accentuated  aortic  second  sound  indicating  hyper- 
tension, or  we  may  encounter  indications  of  a  relative  mitral  leak, 
with  no  complaint  on  the  part  of  the  patient  beyond  a  certain  puffi- 
ness  on  exertion. 

Arterial  hypertension,  except  when  it  occurs  in  association  with 
chronic  nephritis,  is  comparatively  seldom  met  with  before  the  age 
of  forty.  As  an  accompaniment  of  chronic  nephritis  it  is  often 
encountered  in  early  life,  even  during  childhood;  otherwise  it  may 
be  considered  a  disease  of  maturity.  After  forty  years  is  passed 
the  older  the  patient  is  when  hypertension  is  diagnosed  the  more  pro- 
nounced as  a  rule  will  be  the  element  of  arterial  degeneration  and  the 
more  apparant  the  cardiac  secondaries.  In  early  middle  life  unless 
the  elevation  of  blood  pressure  is  the  result  of  nephritis  it  is  apt  to 
stand  unique  as  the  single  physical  indication  of  some  obscure  nutri- 
tive or  toxic  disturbance.   In  many  instances  of  the  kind  hypertension 


ELLIOTT:  ARTERIAL  HYPERTENSION 


649 


is  the  only  thing  present  without  or  previous  to  the  development  of 
organic  secondaries.  Cook  advocates  the  collection  of  these  cases  into 
a  separate  group  for  which  he  suggests  the  name  "essential  arterial 
hypertension."  Under  this  designation  he  would  include  that  residuum 
of  cases  in  which  after  eliminating  all  the  usual  and  known  causes  there 
remains  no  explanation  for  the  one  constant  and  only  physical  sign — 
hypertension  of  the  pulse.  In  practically  all  of  these  cases,  as  he 
states,  there  is  a  certain  element  of  cardiac  hypertrophy,  but  it  may 
be  difficult  to  recognize.  This  definition  very  nearly  coincides  with 
the  presclerosis  of  Huchard.  I  can  best  describe  this  type  of  case 
by  clinical  illustration:  S.  P.,  aged  fifty  years,  was  rejected  at  a  life 
insurance  examination  for  a  policy  of  large  amount,  because  he  had 
a  blood  pressure  of  165  mm.  He  consulted  me  to  determine  its 
cause.  He  was  a  perfectly  healthy  looking  man  of  active  habits  and 
although  a  generous  liver  was  not  intemperate.  He  was  an  excessive 
smoker.  Careful  examination  failed  to  reveal  any  indication  of 
organic  disease.  His  heart  may  have  been  hypertrophied,  but 
regarding  this,  after  repeated  examinations,  I  still  remained  uncertain. 
The  urine  was  free  from  albumin  and  casts  and  of  normal  quantity. 
He  complained  of  flatulency,  but  was  not  constipated.  His  hygiene 
and  diet  were  carefully  regulated,  his  smoking  moderated,  and  in  a 
year  the  blood  pressure  had  descended  to  an  average  of  135  mm. 

This  form  of  primary  arterial  hypertension  is  probably  more 
frequent  than  we  are  aware,  and  if  the  sphygmomanometer  were 
used  on  all  men  of  middle  age  coming  under  observation,  both  in 
clinical  routine  and  life  insurance  examination,  attention  would  be 
directed  to  it  oftener  than  is  now  the  case.  It  is  hardly  likely  that 
we  have  to  do  here  with  a  different  type  of  case  from  those  we  ordin- 
arily class  as  arteriosclerosis  with  hypertension,  or  as  chronic  neph- 
ritis. We  have  encountered  it  in  its  incipiency,  that  is  all,  before 
pronounced  organic  secondaries  have  developed  to  stamp  the  case 
as  arterial,  cardiac,  or  renal.  Should  the  condition  persist  unmodi- 
fied we  would  probably  be  able  to  watch  the  development  of  arterial 
fibrosis  as  the  result  of  prolonged  mechanical  strain  upon  the  vessels, 
of  cardiac  enlargement,  casts  and  albumin,  and  all  the  flock  of 
secondaries  that  characterizes  the  fully  developed  disease. 

The  relationship  of  arteriosclerosis  to  high  blood  pressure  still 
remains  difficult  to  define,  notwithstanding  the  large  amount  of  in- 
vestigation and  discussion  devoted  to  the  problem.  It  is  a  well 
known  clinical  fact  that  the  most  extreme  degeneration  of  palpable 
arteries  may  exist  without  elevation  of  blood  pressure  above  the 
normal  (Dunin,  Groedel,  Elliott).  Equally  common  in  practical 
experience  is  the  existence  of  a  greatly  elevated  blood  pressure  with 
but  slight  fibrosis  of  accessible  arteries.  We  have  to  account  then 
for  the  circumstance  of  an  individual  with  rigid  calcareous  radials 
presenting  a  normal  pressure  for  his  age,  whereas  another  patient 
much  younger  and  possessing  vessels  far  less  degenerated  gives 


650 


ELLIOTT:  ARTERIAL  HYPERTENSION 


pressure  values  double  the  normal.  It  would  appear  that  hardening 
of  the  superficial  vessels  alone  does  not  suffice  seriously  to  disturb 
the  normal  circulatory  pressure.  It  is  necessary  that  we  distinguish 
very  positively  between  the  clinical  type  of  arteriosclerosis  and  hyper- 
tension. They  do  not  by  any  means  go  hand  in  hand  and  when  the 
two  are  found  together  they  may  only  have  an  indirect  relationship. 
The  fact  that  in  most  cases  of  persistent  high  pressure  some  fibrosis 
of  accessible  arteries  can  be  made  out  has  probably  led  us  to  over- 
estimate the  importance  of  arteriosclerosis  in  elevating  blood  pressure. 
Undoubtedly  stiff  arteries  may  cause  some  increase  in  tension  with- 
out the  operation  of  any  second  factor,  but  that  they  can  unaided 
produce  the  excessive  values  we  deal  with  clinically  is  open  to 
question.  "  Arteriosclerosis  is  an  anatomical  change,  whereas  high 
pressure  is  a  functional  disturbance."  Instead  of  arterial  changes 
giving  rise  to  high  pressure  it  is  probable  that  as  often  as  not  when  the 
two  are  found  together  the  sclerosis  has  been  produced  by  the  long- 
continued  strain  on  the  arterial  walls  caused  by  the  hypertension. 
As  a  rule,  however,  cases  of  hypertension  do  not  live  long  enough  to 
develop  a  high  degree  of  arteriosclerosis.  It  is  clear  that  some 
underlying  factor  not  accessible  to  our  present  methods  of  examina- 
tion must  be  responsible  for  the  occurrence  of  high  blood  pressure 
in  arteriosclerosis.  This  factor  we  may  assume  on  general  grounds 
to  lie  in  some  disturbance  of  the  splanchnic  circulation.  In  health 
a  certain  functional  interchange  or  "give  and  take"  exists  between 
the  systemic  and  splanchnic  circuits,  the  systemic  drawing  upon  the 
splanchnic  at  need  and  at  other  times  using  it  as  a  storage  for  blood. 

In  disease  this  "normal  balance"  may  be  greatly  disturbed  and  if  the 
splanchnic  vessels  be  the  seat  of  sclerosis  their  reserve  capacity  will 
be  reduced  and  the  systemic  arterial  pressure  in  consequence  raised 
and  maintained  above  normal.  This  is  practically  the  conclusion 
of  Hasenfeld  and  Hirsch,  who  from  clinical  and  pathological  data 
contend  that  it  is  only  when  the  vessels  of  the  splanchnic  area  or  the 
aorta  above  the  diaphragm  are  diseased  that  high  pressure  develops 
in  arteriosclerosis.  For  the  present  at  least  we  may  assume  that 
when  arterial  pressure  is  persistently  raised  the  terminal  divisions 
of  the  vascular  system  (splanchnic  and  systemic)  are  principally 
involved  in  the  sclerosis.  This  is  of  the  highest  practical  importance 
for  arteriosclerosis  of  the  splanchnics  and  arterioles  cannot  be 
recognized  by  physical  investigation  during  life,  but  may  be  inferred 
to  exist  with  a  fair  degree  of  certainty  from  blood  pressure  observa- 
tions. The  prognosis  in  this  type  of  case  is  very  different  and  far 
graver  than  in  that  other  order  of  sclerotics  with  stiff  chalky  arteries, 
but  no  tension.  As  Cook  has  emphasized,  the  outlook  in  the  case 
of  a  robust  looking  man  of  fifty-five  with  a  blood  pressure  of  200  mm., 
even  with  no  appreciable  arterial  degeneration,  is  not  so  good  as  in 
the  case  of  a  man  of  sixty-five  with  rigid  arteries  and  a  pressure  of 
130  mm.    We  find  many  examples  of  the  latter  type  in  every  old 


ELLIOTT:  ARTERIAL  HYPERTENSION 


651 


peoples'  home  where  they  live  on  year  after  year  eventually  dying 
of  an  atrophy,  cerebral  or  cardiac.  The  patient  with  hypertension 
is  in  daily  danger  of  apoplexy  or  heart  failure.  The  element  of 
danger  is  the  tension. 

Fraenkel  and  Hasenfeld  have  pointed  out  that  corpulent  persons 
of  a  sedentary  habit  are  prone  to  develop  sclerosis  of  the  splanchnic 
vessels  with  high  blood  pressure.  There  is  much  reason  to  believe 
that  such  cases  are  toxic  in  origin  and  it  is  probable  that  the  chief 
source  of  the  pressor  toxins  is  the  digestive  organs.  The  argument 
of  clinical  experience  lends  weight  to  the  contention  of  Russel  that 
in  non-nephritic  cases  the  hypertension  is  caused  by  the  presence  in 
the  blood  of  substances  which  are  absorbed  from  the  alimentary  tract 
and  are  the  product  in  one  form  or  another  of  what  has  been  swallowed 
as  necessary  food  or  as  unnecessary  indulgence.  This  does  not 
imply  that  the  big  feeder  must  necessarily  develop  splanchnic 
sclerosis  and  the  small  feeder  escape.  The  essental  factor  will 
prove  to  be  the  digestive  and  eliminative  competency  of  the  individual 
and  the  relative  suitability  of  his  diet.  In  summing  up  the  relation 
between  arteriosclerosis  and  high  blood  pressure  we  must  acknow- 
ledge in  the  first  place  that  the  thickening  of  the  vessel  walls  incident 
to  age  is  capable  of  causing  a  gradual,  but  by  no  means  extreme  rise 
in  the  average  arterial  pressure.  We  see  this  in  the  slow  increase  of 
average  pressure  readings  as  life  advances,  a  pressure  of  140  mm. 
being  accounted  normal  for  a  man  of  sixty-five  years,  whereas  his 
son  will  have  a  pressure  of  120  mm.  and  his  grandson  100  mm. 
Should  the  pressure  of  such  a  man  register  persistently  above  160  mm. 
and  with  this  his  heart  show  enlargement  he  may  be  regarded  as 
having  hypertension  and  we  must  invoke  some  cause  other  than  his 
arteriosclerosis  to  explain  it.  Such  a  development  means  that  in 
addition  to  a  thickened  artery  he  has  a  constricted  one,  the  former 
an  anatomical  change,  the  latter  a  spastic  condition  produced  by 
some  toxic  excitant  circulating  in  the  blood  and  causing  hypertonic 
contraction  of  the  arterioles,  splanchnic  or  systemic  (Russel). 

It  is  hardly  necessary  to  urge  the  importance  of  carefully  investi- 
gating the  condition  of  the  urine  in  every  instance  of  hypertension. 
The  frequency  with  which  chronic  renal  disease  is  associated  with 
cardiovascular  changes  is  well  known  and  no  factor  is  so  potent  as 
nephritis  in  the  production  of  high  blood  pressure.  If  a  diagnosis 
of  chronic  interstitial  nephritis  can  be  made  it  is  not  necessary  to 
search  farther  for  the  cause  of  high  pressure.  At  the  same  time  it  is 
to  be  remembered  that  greater  care  than  ordinary  is  required  to 
diagnose  nephritis  in  the  presence  of  arteriosclerosis  with  high  blood 
pressure,  owing  to  the  fact  that  some  degree  of  atrophy  of  the  kidneys, 
manifested  by  slight  albuminuria  and  casts,  is  almost  always  present 
as  a  consequence  of  those  organs  sharing  in  the  general  vascular 
deterioration.  Moreover,  almost  all  cases,  no  matter  of  what  origin, 
showing  blood  pressures  over  200  mm.  will  display  some  albumin  in 


652 


ELLIOTT:  ARTERIAL  HYPERTENSION 


the  urine.  It  is  unfortunate  that  no  clear  distinction  is  made  in 
clinical  literature  between  arteriosclerotic  renal  atrophy,  and  true 
contracting  kidney.  Every  experienced  clinician  knows  how  vast 
the  difference  is  in  course,  prognosis,  and  treatment  between  the 
two  conditions,  and  yet  it  is  only  from  experience  and  not  from 
medical  literature  that  one  learns  to  appreciate  the  distinction. 
Chronic  interstitial  nephritis  is  an  inveterate  organic  lesion  showing 
severe  toxic  manifestations,  a  steady  and  even  rapid  downward 
progression,  is  not  amenable  to  treatment,  and  has  a  bad  prognosis. 
In  every  respect,  no  matter  how  similar  may  be  its  urinary  and 
physical  indications,  arteriosclerotic  renal  atrophy  is  the  opposite 
of  this,  being  slow  in  development  and  progress  as  is  the  case  with 
the  sclerotic  atrophies  generally.  A  distinction  between  the  two  is 
important  owing  to  the  difference  in  prognosis. 

Chronic  interstitial  nephritis  gives  rise  to  the  highest  systolic 
readings  that  are  observed  clinically,  pressures  of  300  mm.  and 
higher  being  recorded.  The  highest  record  I  have  is  285  mm.  in  a 
young  woman,  who  died  a  fortnight  after  in  uremic  coma.  In  a 
study  of  60  cases  of  chronic  nephritis1  the  average  pressure  was  190 
mm.  Chronic  nephritis  is  essentially  a  disease  of  systemic  scope, 
involving  the  heart  and  arteries  as  well  as  the  kidneys.  Arterial 
hypertension  is  one  of  its  salient  features.  Notwithstanding  occa- 
sional exceptions  to  the  rule,  high  pressure  is  so  significant  that  it 
constitutes  one  of  the  most  valuable  diagnostic  indications  of  that 
disease.  The  use  of  the  sphygmomanometer  and  the  discovery  of 
high  pressure  will  at  once  put  the  observer  on  the  alert. 

The  attempt  to  establish  a  working  hypothesis  to  account  for  all 
the  varieties  of  hypertension  leads  us  face  to  face  with  the  toxic 
theory.  Arterial  hypertension  is  best  exemplified  as  it  occurs  in  a 
group  of  chronic  diseases  having  as  their  common  essential  char- 
acteristic, toxemia.  In  all  probability  the  materies  morbi  consists 
of  certain  abnormal  biochemical  products  present  in  the  circulating 
blood.  This  is  apparent  in  scarlatinal  nephritis  in  which  the  tension 
rises  a  few  hours  after  the  appearance  of  albumin  in  the  urine, 
entirely  too  early  for  the  rise  to  be  explained  by  the  formation  of 
arterial  fibrosis.  The  high  tension  of  uremia  is  another  instance 
in  point.  For  laboratory  proofs  we  have  the  well-known  fact  that 
the  pressor  principle  of  adrenal  and  pituitary  glands  and  also  certain 
drugs  (ergot,  nicotin,  digitalis)  will  raise  blood  pressure.  That 
hypertension  is  a  functional  effect,  as  well  as  an  organic  product,  we 
may  infer  from  the  clinical  observation  that  measures  designed  to 
detoxicate  the  system  (diet,  sweats,  cathartics)  will  result  in  some 
reduction  of  pressure  in  most  cases  of  hypertension,  and  the  thera- 
peutic action  of  the  nitrites  could  not  be  secured  did  the  condition 
rest  solely  on  a  basis  of  structural  change. 


1  Jour.  Amer.  Med.  Assoc.,  April  13,  1907. 


ELLIOTT:  ARTERIAL  HYPERTENSION 


653 


The  end-effects  of  long  continued  high  blood  pressure  are  mani- 
fested principally  in  the  heart  and  arteries.  The  arterial  walls 
reacting  to  the  excessive  mechanical  strain  undergo  a  progressive 
structural  deterioration  to  the  great  prejudice  of  their  normal  his- 
tology and  vasomotor  tonus.  In  the  end  vasomotor  response  may 
be  so  seriously  disturbed  that  nitrites  may  fail  to  lower  blood  pressure. 
Peripheral  resistence  increases  in  this  manner  with  the  stage  of  the 
disease.  A  somewhat  parallel  sequence  of  events  is  apparent  in  the 
heart.  At  first  in  response  to  overwork  the  myocardium  hyper- 
trophies just  as  does  the  myarterium.  The  peripheral  retard  being 
persistent  and  increasing  and  the  heart  reserve  limited,  myocardial 
insufficiency  becomes  inevitable.  The  heart  at  first  hypertrophies 
and  then  dilates  in  the  face  of  continued  overstrain. 

The  complications  of  arterial  hypertension  will  be  determined 
by  the  ability  of  the  different  organs  to  withstand  the  strain.  On  the 
part  of  the  heart  we  observe  hyposystole  and  asystole,  of  the  arteries 
atheroma,  of  the  kidneys  albuminuria  and  uremia.  A  cerebral 
vessel  may  give  way  and  apoplexy  close  the  scene. 

The  symptomatology  of  arterial  hypertension  is  general  rather  than 
special.  There  may  be  an  entire  lack  of  symptoms  until  vertigo 
or  an  attack  of  acute  dyspnoea  alarms  the  patient,  or  some  cerebral 
accident  occurs.  The  condition  is  often  revealed  quite  unexpectedly 
during  examination  for  life  insurance.  Frequently  the  earliest 
symptoms  are  of  nervous  type,  irritability,  depression  of  spirits, 
disturbed  sleep,  or  it  may  be  that  the  patient  complains  of  bilious 
symptoms,  flatulency,  constipation,  headaches,  and  vertigo.  There 
is  usually  precordial  discomfort  and  dyspnoea  following  effort  and 
the  patient  rises  once  or  more  at  night  time  to  void  urine.  As  a 
rule  the  night  urine  exceeds  in  quantity  that  passed  during  the  day. 
A  symptom  noted  in  a  number  of  my  cases  is  a  severe  paroxysmal 
flatulency  nocturnal  in  occurrence  or  developing  on  exertion.  During 
the  intervals  between  attacks  there  may  be  no  complaint  of  flatulency, 
and  examination  at  any  time  may  fail  to  reveal  special  tympany  or 
distention.  Shortly  after  retiring  for  the  night  the  patient  may 
experience  a  feeling  of  distention  and  oppression  across  the  lower 
chest  or  he  may  awake  after  a  period  of  sound  sleep  with  a  feeling 
as  if  the  stomach  were  full  of  gas.  Instinctively  he  strives  to  relieve 
himself  by  gulping,  drinking  hot  aromatic  or  alcoholic  drinks,  and 
the  fact  that  comfort  is  reestablished,  frequently  after  an  hour  or 
more,  only  when  he  has  belched  freely,  confirms  him  in  his  idea  that 
it  is  indigestion.  The  breathing  is  usually  hurried,  and  palpitation 
may  coincide.  Attacks  of  this  nature  may  develop  after  exertion, 
especially  soon  after  meals  and  most  frequently  during  the  early  part 
of  the  day.  Bending  over,  lifting,  straining  at  stool  may  precipitate 
the  symptom.  This  development  is  probably  similar  in  character 
and  significance  to  cardiac  asthma  and  denotes  insufficiency  of  the 
right  heart.    All  of  the  patients  with  this  symptom  whom  I  have  seen, 

VOL   139,  NO.  5. — MAY,  1910.  22 

/ 


654 


ELLIOTT:  ARTERIAL  HYPERTENSION 


have  had  enlarged  livers  and  one  a  well  marked  jugular  pulse.  I 
have  come  to  regard  flatulency  of  irregular  and  paroxysmal  occur- 
rence in  mature  individuals  as  extremely  significant,  and  I  believe 
that  every  such  case  should  be  carefully  investigated  as  to  the 
cardiovascular  condition.  A  typical  instance  of  this  character  is 
the  following  case. 

S.  F.,  aged  seventy-six  years,  and  weighing  one-hundred  and  ninety 
pounds,  is  a  retired  merchant  of  means,  and  boasts  that  he  has  never 
been  sick  in  his  life.  He  confesses  that  he  has  been  a  very  hearty 
eater  and  heavy  smoker,  and  has  for  years  been  constipated.  Al- 
though rather  spare  in  his  limbs  he  is  round-bellied  and  his  face  is 
ruddy  and  somewhat  pigmented.  He  complains  that  for  some 
months  he  has  been  greatly  troubled  with  attacks  of  explosive  belch- 
ing of  gas  developing  during  exertion  and  interfering  greatly  with 
his  activities.  These  attacks  are  frequent  during  the  early  part  of 
the  day,  especially  after  breakfast  and  occur  comparatively  seldom 
and  less  severely  toward  evening.  They  come  on  during  walking, 
especially  if  the  weather  is  cold  or  it  is  windy  or  the  walking  rough. 
He  is  compelled  to  sit  down  or  lean  against  a  fence  or  building  until 
he  had  relieved  himself  by  belching.  There  is  little  intestinal  flatus, 
and  but  slight  dyspnoea  between  the  attacks.  He  is  somewhat  puffy 
on  exertion.  He  rises  two  to  four  times  at  night  to  void  urine.  He 
is  found  on  examination  to  have  a  greatly  enlarged  heart,  the  apex 
17  cm.  from  the  midsternum;  and  a  systolic  blow  at  the  mitral  area 
reveals  the  lea  of  dilatation.  The  blood  pressure  ranges  from  190 
mm.  to  225  mm.  There  are  no  urinary  indications  of  nephritis. 
This  patient  remained  under  observation  for  two  months  with  slight 
benefit  to  his  symptoms  and  then  departed  south  to  a  more  agree- 
able wi  nter  climate.  Two  weeks  after  his  departure  he  died  of  acute 
heart  failure. 

It  is  noted  frequently  by  patients  with  hypertension  that  smoking 
causes  restlessness  and  cerebral  discomfort  and  that  heavy  meals 
are  not  so  well  borne  as  formerly.  Women  are  apt  to  complain  of 
flushing  and  burning  of  the  face,  and  if  in  the  middle  period  of  life 
are  apt  to  ascribe  it  to  the  climacteric.  I  have  noted  as  a  prominent 
symptom  in  two  cases  pains  of  an  anginoid  character  referred  to  the 
precordium,  the  left  arm,  or  abdomen  following  exertion.  Tachy- 
cardia a^  d  palpitation  are  complained  of.  As  a  sign  of  great  signi- 
ficance and  rather  grave  import,  as  it  indicates  the  beginning  of  hypo- 
systole,  is  dyspnoea  on  lying  down.  The  explanation  of  this  develop- 
ment lies  in  the  fact  that  the  arterioles  being  contracted  the  blood 
collects  unduly  in  the  veins  especially  the  splanchnic  veins.  When 
the  patient  is  upright  these  veins  act  as  a  reservoir,  but  when  he  lies 
down  the  force  of  gravity  tends  to  empty  them  into  the  right  heart. 
This  leads  to  overdistention  of  the  pulmonary  capillaries  and 
dyspnoea.  The  only  way  rightly  to  interpret  these  symptoms  is  to 
take  the  blood  pressure.    With  every  individual  of  middle  age  com- 


deaver:  use  and  abuse  of  gastroenterostomy  655 

plaining  of  persistent  functional  disturbance  this  precaution  should 
never  be  omitted. 

Examination  of  the  heart  in  cases  of  hypertension  will  reveal 
enlargement  of  that  organ.  This  may  sometimes  be  difficult  of 
detection  in  fat  individuals  and  in  women  with  pendant  breasts.  In 
the  earlier  stages  the  heart  sounds  are  usually  clear,  the  first  tone 
booming  and  prolonged,  the  aortic  second  loud,  valvular,  and  ringing. 
If  the  ventricle  has  dilated  the  murmur  of  relative  mitral  insuffi- 
ciency may  be  heard.  Late  in  the  case  with  the  heart  badly  dis- 
organized, the  patient  dropsical,  and  the  pulse  small  and  arrhythmic, 
it  may  become  extremely  difficult  to  determine  whether  the  case  is  one 
of  cardiac  failure  from  prolonged  hypertension  or  a  valve  lesion  in  the 
final  stage  of  incompensation.  The  sphygmomanometer  may  afford 
us  no  help  at  this  juncture,  owing  to  the  failure  of  the  ventricle  having 
so  impaired  the  support  of  the  circulation  as  to  induce  secondary 
low  blood  pressure.  One  must  then  fall  back  upon  the  history  and 
the  general  features  of  the  case  to  decide  the  point. 

Analysis  of  the  urine  in  arterial  hypertension  may  reveal  no  morbid 
elements  from  the  kidney,  although  in  cases  of  some  standing  a  few 
hyaline  casts  will  usually  be  found.  If  chronic  nephritis  exists  the 
usual  urinary  characteristics  of  that  disease  will  appear  to  point  to  the 
origin  of  the  hypertension.  Renal  permeability  to  albumin  seems 
to  be  overcome  when  the  blood  pressure  reaches  or  exceeds  200  mm., 
so  that  cases  with  very  high  pressures,  whether  primarily  nephritis 
or  not,  usually  have  albumin  in  the  urine. 


THE  USE  AND  ABUSE  OF  GASTROENTEROSTOMY.1 

By  John  B.  Deaver,  M.D.,  LL.D., 

SURGEON-IN-CHIEF  TO  THE  GERMAN  HOSPITAL,  PHILADELPHIA. 

Gastroenterostomy,  "the  keystone  of  gastric  surgery,"  was 
first  performed  in  1881.  Today  this  operation  is  being  frequently 
made.  The  object  of  this  paper  is  to  excite  discussion  upon  the 
bearing  of  the  operation  along  the  lines  where  it  is  proper  as  well 
as  improper.  The  risks  of  gastro-enterostomy  performed  by  an 
experienced  surgeon  are  inconsiderable.  The  mortality  of  gastro- 
enterostomy in  benign  disease  is  low,  1  to  2.5  per  cent.  This  is 
fortunate  in  a  sense,  and  yet  unfortunate  if  it  encourages  the  per- 
formance of  the  operation  in  conditions  in  which  it  is  not  properly 
indicated. 

A  most  important,  essential,  and  interesting  point  is  that  metab- 

1  Read  at  a  meeting  of  the  Manhattan  Medical  Society,  New  York,  December  17,  1909. 


656      deaver:  use  and  abuse  of  gastroenterostomy 

olism  after  gastroenterostomy  is  not  interfered  with  to  the  degree 
of  making  the  operation  objectionable  on  this  account.  It  has  been 
clearly  demonstrated  by  observers,  particularity  Paterson,  that 
metabolism  is  in  no  way  seriously  altered.  It  has  been  my  expe- 
rience, after  observing  a  large  number  of  cases  several  years  after 
operation,  that  not  only  has  the  patient's  digestive  ability  been  in 
no  way  impaired,  but  that  he  was  able  to  take  more  freely  of  food, 
even  such  as  could  not  be  digested  before.  The  ultimate  results  of 
gastro-enterostomy  have  been  most  satisfactory.  This  has  been 
demonstrated  by  collected  cases,  notably  those  of  Mayo,  Moynihan, 
myself,  and  others. 

Formerly  the  most  dreaded  complication  of  gastro-enterostomy 
was  regurgitant  vomiting.  This,  since  the  no-loop  operation  has 
been  done,  is  practically  a  thing  of  the  past.  I  was  unfortunate 
enough  to  see  a  few  of  these  cases  when  I  practised  the  long-loop 
operation,  but  have  not  had  a  case  of  the  kind  since  doing  the  no- 
loop  operation.  One  of  my  cases  of  regurgitant  vomiting  necessi- 
tated five  operations  before  I  was  able  to  correct  it.  The  cause  of 
regurgitant  vomiting  was  believed  to  be  the  presence  of  bile  in  the 
stomach  from  the  afferent  loop,  but  it  has  been  established  by 
experiments  on  dogs  that  bile  in  the  stomach  has  no  injurious  effect 
on  digestion  or  the  general  health.  In  confirmation  of  this,  Moy- 
nihan has  reported  a  case  in  which  the  result  of  rupture  of  the  intestine 
at  the  junction  of  the  duodenum  and  jejunum  necessitated  closing 
the  duodenal  end  of  the  bowel  and  transplanting  the  jejunal  end 
into  the  stomach,  thereby  causing  all  the  bile  to  enter  the  stomach 
through  the  pylorus;  the  patient  never  suffered  from  vomiting,  and 
remained  in  good  health  several  weeks  after  the  accident,  until  his 
death,  which  was  caused  by  perforative  peritonitis,  due  to  the 
Murphy  button.  Some  surgeons,  notably  Kehr,  perform  chole- 
cystogastrostomy  in  preference  to  cholecystocolostomy. 

It  has  been  my  practice  to  place  an  anchor  suture  one-half  to  one 
inch  distant  from  the  commencement  of  the  efferent  portion  of  the 
bowel,  in  this  wise  preventing  angulation  and  consequent  spur 
formation,  thus  minimizing  the  chances  of  obstruction  to  the  onward 
passage  of  the  contents  of  the  afferent  loop.  I  believe  that  the 
cause  of  regurgitant  vomiting  probably  has  been  a  mechanical 
defect  at  the  site  of  the  pnastomotic  opening,  therefore  faulty  tech- 
nique. Other  complications  after  the  operation,  as  detailed  by 
Moynihan,  are  hemorrhage,  internal  hernia,  separation  of  united 
viscera  (leakage),  formation  of  adhesions  at  or  near  the  point  of 
new  opening,  peptic  ulcer,  pneumonia,  and  diarrhoea. 

I  have  never  encountered  hemorrhage.  I  have  never  had  a  case 
of  internal  hernia  or  separation  of  united  viscera,  or  leakage.  In- 
ternal hernia  is  prevented  by  careful  suture  of  the  margin  of  the 
opening  in  the  mesocolon  to  the  wall  of  the  stomach.  To  my  mind 
that  is  more  rational  than  suture  of  the  margin  of  the  opening  in  the 


deaver:  use  and  abuse  of  gastroenterostomy  657 

mesocolon  to  the  bowel.  Suture  of  the  mesocolon  to  the  bowel,  if 
followed  by  contraction  of  the  marginal  mesocolon,  may  so  constrict 
the  bowel  as  to  cause  obstruction  of  the  anastomotic  opening  and 
interfere  with  the  passage  of  the  contents  of  the  duodenum  into  the 
bowel  beyond  the  anastomotic  opening.  In  this  connection  I  might 
say  that  the  surgeon  should  be  a  good  cutter  and  a  good  sewer  to 
avoid  mechanical  complications.  I  have  seen  the  formation  of 
adhesions  at  or  near  the  new  opening;  and  also  pneumonia;  but 
never  peptic  ulcer  or  profuse  diarrhoea. 

The  conditions  for  which  the  operation  of  gastro-enterostomy  is 
indicated  are :  Chronic  gastric  and  duodenal  ulcer,  with  their  sequels, 
perforation,  recurrent  hemorrhage,  and  cicatricial  contraction;  car- 
cinoma of  the  pylorus,  in  connection  with  excision  or  alone  by 
way  of  palliative  treatment;  benign  pyloric  obstruction  resulting 
from  stricture,  adhesions,  or  angulation;  gastric  tetany;  gastro- 
ptosis,  with  loss  of  stomach  motility,  and  therefore  with  stagnation 
and  usually  more  or  less  dilatation;  chronic  dilatation,  without 
gastroptosis,  with  stagnation  from  loss  of  motility;  infantile  hyper- 
trophic stenosis  of  the  pylorus;  duodenal  cancer  or  tumor  causing 
obstruction;  duodenal  fistula;  the  rare  cases  of  plastic  linitis  of  the 
stomach,  in  which  the  hypertrophy  of  the  walls  reduces  the  stomach 
to  such  a  size  that  only  liquid  in  small  quantities  may  be  taken  and 
retained. 

The  conditions  in  which  the  operation  is  contra-indicated,  there- 
fore, in  which  the  operation  is  an  abuse,  are:  Acute  dilatation 
of  the  stomach,  gastric  neuroses,  dilatation  without  stagnation, 
advanced  carcinoma  of  the  pylorus,  and  gastric  crises. 

This  operation  does  good  in  chronic  gastric  and  duodenal  ulcer 
by  diminishing  the  acidity,  by  abating  pylorospasm,  and  possibly  by 
allowing  the  entrance  of  greater  quantities  of  bile  into  the  stomach, 
removing  the  condition  which  has  prevented  healing  of  the  ulcer. 
About  80  per  cent,  of  patients  operated  on  for  gastric  ulcer  by 
gastro-enterostomy  recover.  That  gastric  ulcer  is  frequently 
multiple  must  be  acknowledged.  It  is  true  that  we  have  no  patho- 
logical evidence  that  gastric  ulcer  is  healed  following  the  operation 
of  gastro-enterostomy,  yet  we  have  clear  clinical  evidence  that  this 
is  so.  The  mortality  of  gastric  ulcer  treated  medically  is  about 
20  per  cent.,  and  at  least  50  per  cent,  of  cures,  so-called,  relapse, 
and  probably  not  25  per  cent,  of  patients  treated  medically  are 
really  cured.  The  proportion  of  cases  of  relapse  after  cure  follow 
ing  gastro-enterostomy  is  about  10  per  cent. 

If  the  ulcer  is  not  located  at  the  pylorus,  the  latter  therefore  opens, 
and  the  contents  of  the  stomach  will  partly  pass  through  it  as  well  as 
the  new  opening.  The  churning  and  propulsive  movements  of  the 
stomach,  which  are  later  taken  up  by  the  pylorus  and  carried  on 
through  the  duodenum  and  small  intestine,  are  not  interfered  with. 
Some  of  the  stomach  contents  pass  through  the  new  opening,  as  the 


658      deaver:  use  and  abuse  of  gastroenterostomy 


cut  circular  muscular  fibers,  the  agents  in  the  propulsive  move- 
ments, are  attached  to  the  margins  of  the  new  opening,  and  in  con- 
tracting separate  the  margins  of  the  opening  and  thus  allow  the 
stomach  partly  to  empty  through  this  route.  In  complete  pyloric 
obstruction  all  of  the  gastric  contents,  as  a  matter  of  course,  pass 
out  by  way  of  the  anastomotic  opening. 

As  this  paper  deals  with  gastro-enterostomy  alone,  I  have  said 
nothing  about  the  excision  of  the  gastric  ulcer.  There  is  a  great 
difference  of  opinion  as  to  the  relative  merits  of  excision  and  gastro- 
enterostomy. The  strongest  argument  in  favor  of  excision  is  the 
likelihood  of  carcinoma  becoming  engrafted  on  the  ulcer  scar.  The 
decision,  pro  or  con,  is  best  made  at  the  time  of  operation,  according 
to  the  appearance  and  consistency  of  the  ulcer.  A  thickened, 
greatly  indurated  ulcer  is  better  excised,  since  it  is  impossible  to 
determine  whether  malignant  changes  may  not  already  have  taken 
place,  and  experience  tells  us  that  a  considerable  percentage  of 
those  excessively  hard  and  thickened  ulcers  do  show  carcinomatous 
changes.  Unless  there  is  a  suspicion  of  malignancy,  however, 
gastro-enterostomy  is  the  operation  of  choice,  as  showing  a  con- 
siderably smaller  mortality. 

The  operation  is  strongly  indicated  in  cases  of  recurrent  bleeding, 
in  which  the  intervals  between  bleedings  are  growing  shorter,  and 
the  amount  of  blood  lost  the  equivalent  or  more  than  on  previous 
occasions.  The  following  case  is  an  illustration  of  operation  for  this 
condition : 

Miss  ,  aged  twenty-six  years.    In  1903  she  noticed  the  first 

symptoms,  which  subsequently  suggested  gastric  ulcer.  She  was 
miserable  for  two  years,  when  she  was  again  attacked  with  symp- 
toms referable  to  the  stomach.  In  August,  1907,  she  had  an  attack 
of  severe  abdominal  pain,  continuing  for  three  days.  Nothing 
remained  in  her  stomach;  she  suffered  from  nausea  and  vomiting, 
which  continued  for  two  weeks.  On  August  23,  after  taking  a 
small  quantity  of  beef  juice,  she  had  a  very  severe  hemorrhage, 
followed  by  several  smaller  hemorrhages  at  intervals.  I  saw  the 
patient  on  August  30,  with  the  physician  in  charge,  Dr.  Branson. 
As  she  had  not  vomited  for  two  or  three  days  before  my  visit,  and 
her  condition  was  so  wretched,  we  agreed  to  defer  operation  for 
a  few  days. 

Operation,  September  3,  1907.  Exposure  of  the  stomach  showed 
a  saddleback  ulcer  on  the  lesser  curvature,  four  inches  from  the 
pylorus,  with  greatly  indurated  edges.  Subtotal  gastrectomy  and 
gastro-enterostomy  were  done.    Recovery  was  uneventful. 

In  hour-glass  stomach  gastrojejunostomy  makes  a  part  of  the 
necessary  interference.  This  operation  alone  will  seldom  suffice, 
as  when  made  in  the  pyloric  pouch  only  the  obstruction  to  the 
passage  of  food  from  the  cardiac  pouch  still  exists,  and  when  made 
in  the  cardiac  pouch  alone  it  will  not  drain  the  pyloric  pouch;  hence 


deaver:  use  and  abuse  of  gastroenterostomy 


659 


it  is  necessary,  in  addition  to  gastro-enterostomy  at  the  pyloric 
pouch,  to  do  a  gastrogastrostomy  or  gastroplasty,  so  as  to  place  the 
two  pouches  in  communication. 

Gastro-enterostomy  is  indicated  when  a  perforated  ulcer  of  the 
stomach  or  duodenum  is  sutured,  if  the  patient  is  bearing  the  anes- 
thetic well.  It  has  always  been  my  practice  to  do  this  operation  in 
connection  with  the  closure  of  the  ulcer.  I  know  there  are  many 
surgeons  who  take  the  opposte  stand;  nevertheless,  I  am  of  the 
opinion  that  it  is  proper  to  do  it  if  the  patients  are  operated  on  com- 
paratively early.  Patients  that  are  operated  on  late  after  perforation 
die,  do  what  one  will.  The  additional  time  which  gastro-enteros- 
tomy takes  when  closing  a  perforated  ulcer  of  the  duodenum  or 
stomach  is  a  matter  of  no  moment  if  the  operation  is  done  at  a 
timely  season.  The  chief  advantages  of  making  the  anastomosis 
is  to  make  the  patient  permanently  well  after  he  recovers  from  the 
closure  of  the  perforation,  which  is  too  frequently  not  the  case  when 
this  is  not  done,  the  patient  continuing  to  suffer  from  indigestion. 
In  the  event  that  another  ulcer  has  been  overlooked,  this  places  the 
patient  in  the  best  position  for  permanent  relief.  The  surgeon  will 
have  more  confidence  in  closing  the  ulcer,  particularly  if  it  has 
indurated  borders,  and  he  will  not  fear  having  caused  too  much 
obstruction  to  the  lumen  of  the  viscus.  The  operation  of  gastro- 
enterostomy puts  the  part  at  rest  and  makes  healing  certain  and 
quicker,  and  therefore  lessens  the  risk  of  leakage;  allows  us  to  feed 
our  patients  earlier,  which  is  of  some  moment  in  a  certain  percentage 
of  cases.  Yet  I  may  say  here  that  I  never  had  any  trouble  in  nour- 
ishing my  patients  for  the  first  two  or  three  days  by  the  bowel,  by 
giving  saline  solutions  and  expressed  beef  juice.  In  fact,  I  think 
patients,  as  a  rule,  do  not  require  anything  in  the  shape  of  food  for 
two  or  three  days  after  the  operation. 

In  carcinoma  involving  the  pyloric  end  of  the  stomach,  too  far 
advanced  for  radical  operation,  and  the  patient's  general  condition 
being  fairly  good,  and  indicating  that,  if  able  to  take  nourishment, 
his  life  would  be  prolonged  for  several  months  and  his  comfort 
increased,  the  operation  is  warrantable.  I  believe  that  gastro- 
enterostomy is  often  performed  in  carcinoma  of  the  stomach  that  is 
radically  inoperable,  when  it  had  better  not  be  done,  as  it  only  adds 
misery  to  misery. 

That  gastro-enterostomy  is  the  only  alternative  in  benign  pyloric 
obstruction  due  to  cicatricial  contraction,  adhesions,  or  angulation 
goes  without  saying.  The  exception  would  be  an  occasional 
Finney  operation  in  exudative  contraction,  yet  I  am  of  the  opinion 
that  gastro-enterostomy  here  is  the  better  operation  from  the  stand- 
point of  ultimate  results. 

In  gastroptosis  with  or  without  dilatation  and  with  stagnation, 
and  in  dilatation  with  stagnation,  gastro-enterostomy  is  strongly 
indicated,  providing  the  patient  has  received  treatment  in  the  shape 


660        BEAVER:  USE  AND  ABUSE  OP  GASTROENTEROSTOMY 

of  lavage,  diet,  gymna  sties,  and  attention  to  general  hygiene,  without 
recovery.  In  dilatation,  unless  the  case  yields  very  quickly  to  diet 
and  treatment,  it  should  be  explored.  It  is  not  fair  to  the  patient 
to  withhold  relief  in  the  presence  of  chronic  dyspepsia  that  does 
not  yield  to  medical  means,  thus  exposing  the  patient  to  the  greater 
risks  of  delay.  The  frequency  with  which  chronic  dyspepsia 
proves  at  operation  to  be  due  to  some  tangible  cause  is  a  striking 
fact  in  practice.  The  necessity  for  the  habitual  use  of  the  stomach 
tube  is  sufficient  indication  for  gastro-enterostomy. 

In  infantile  hypertrophic  stenosis,  in  which  the  symptoms  per- 
sist in  spite  of  lavage  and  careful  feeding,  gastro-enterostomy 
promises  most,  but  must  not  be  deferred  until  hope  of  cure  is  out 
of  the  question.  In  duodenal  ulcer  the  rationale  for  gastro-enter- 
ostomy is  the  same  as  in  gastric  ulcer.  In  duodenal  tumor, 
duodenal  fistula,  and  gastric  tetany,  it  may  be  necessary  to  resort 
to  this  operation.  In  plastic  linitis  I  have  seen  excellent  results. 
At  present  I  have  in  mind  one  case  of  a  doctor  who  had  not  been 
able  to  take  anything  but>  liquids,  and  these  in  small  quantities,  for 
a  number  of  years,  owing  to  this  condtiion.  Following  gastro- 
enterostomy he  was  restored  to  practically  a  normal  condition. 
The  stomach  in  this  patient  was  one  and  one-half  inches  in  vertical 
diameter,  two  inches  in  fore  and  aft,  with  walls  an  inch  thick. 

The  operation  is  abused  if  done  in  advanced  cases  of  carcinoma 
with  marked  cachexia.  I  am  quite  sure  that  in  many  cases  of 
carcinoma  of  the  pylorus  the  operation  is  ill  advised.  The  mortality 
of  subtotal  gastrectomy  in  the  latter  class  of  cases  is  so  little  greater 
than  gastro-enterostomy,  that  I  question  the  propriety  of  gastro- 
enterostomy in  the  presence  of  a  growth  that  can  be  excised  without 
injuring  the  pancreas,  if  the  glandular  involvement  be  not  too 
extensive.  Injury  of  the  pancreas,  if  followed  by  escape  of  the 
pancreatic  ferments,  which  cause  necrosis  of  the  tissues  with  which 
they  come  in  contact,  is  a  serious  condition.  When  the  profession 
awakes  to  the  importance  of  opening  the  abdomen  early  in  the  case 
of  chronic  dyspeptics,  gastro-enterostomy  will  have  a  small  place 
in  the  surgery  of  carcinoma  of  the  stomach,  except  in  connection 
with  excision.  That  the  operation  is  much  abused  if  done  in  cases 
of  gastric  crises  we  will  all  agree. 

In  acute  dilatation  of  the  stomach  the  operation  of  gastro-enter- 
ostomy will  never  be  required  if  the  stomach  tube  is  used  earlier 
and  oftener  in  persistent  nausea,  not  waiting  until  there  is  vomiting 
in  that  class  of  cases  in  which  we  are  not  surprised  to  see  it.  In  my 
surgical  work  the  stomach  tube  is  used  to  the  exclusion  of  any  and 
all  medication,  formerly  and  still  believed  by  many  to  be  worth  a 
trial.  The  time  lost  in  giving  medicines,  with  the  hope  that  they 
will  do  good,  is  the  very  time  that  lavage  is  to  be  practised  if  we  are 
to  prevent  this  serious  complication.  In  chronic  dilatation,  with 
or  without  prolapse,  if  there  be  no  motor  insufficiency  or  stagnation, 
the  operation  is  useless. 


deaver:  use  and  abuse  of  gastroenterostomy  661 


There  is  no  doubt  that  there  are  certain  morbid  gastric  conditions 
which  have  been,  and  are  still,  classified  as  neuroses.  What  concerns 
us  particularly  is  that  set  of  gastric  symptoms  classed  grossly  as 
"nervous  dyspepsia."  Under  this  general  term  have  been  grouped 
the  most  diverse  symptom-complexes,  with,  as  a  rule,  but  little 
understanding  of  the  underlying  principles  of  the  case.  It  is  true 
that  there  are  certain  disturbances  in  the  gastric  function,  motor, 
secretory,  and  sensory,  for  which  we  can,  by  the  minutest  exami- 
nation, find  no  organic  basis.  Besides  grouping  them  into  these 
three  classes,  we  may  also  classify  them  as  conditions  of  irritation 
or  depression.  Thus,  gastralgia,  nausea,  and  gastric  hyperesthesia 
are  prominent  types  of  sensory  disturbances;  hyperchlorhydria  and 
hypersecretion  are  well-known  types  of  secretory  disturbances; 
while  atony,  pylorospasm,  and  pyloric  insufficiency  represent  well- 
known  varieties  of  motor  disturbance.  Needless  to  say,  motor, 
sensory,  and  secretory  aberrations  may  all  be  combined  in  a  given 
case,  and  it  is  by  various  combinations  that  the  different  types  of 
so-called  "nervous  dyspepsia"  are  produced. 

As  a  fundamental  principle,  we  can  safely  state  that  a  gastric 
neurosis  without  other  neuroses  or  neurasthenic  conditions  is  a 
most  rare  thing.  The  gastric  symptoms,  however,  may  so  over- 
shadow all  others  that  attention  is  directed  only  to  them. 

In  sensory  disturbances  we  find  more  or  less  anorexia,  or  at  least 
capriciousness  of  appetite,  in  almost  every  case.  It  is  such  a  con- 
stant symptom  that  it  is  of  little  value;  practically  every  sufferer 
from  every  form  of  gastric  disease,  real  or  imagined,  complains  of 
it  at  one  time  or  another.  True  gastralgia  I  have  found  rarely. 
Of  the  secretory  disturbances,  hyperchlorhydria  is  the  most  impor- 
tant. Our  ability  to  diagnosticate  the  condition  by  analyses  of 
stomach  contents  and  secretions  is  not  great,  yet  extreme  cases  can 
be  diagnosticated  in  this  way,  and  do  at  times  occur  in  the  absence 
of  anything  that  would  seem  to  account  for  the  condition.  Atony 
of  the  stomach  also  cannot  at  times  be  considered  as  anything  but  • 
a  neurosis,  and  its  treatment  falls  fully  as  much  within  the  province 
of  the  surgeon  as  of  the  internist.  In  the  diagnosis  we  are  again 
confronted  by  the  lack  ot  exactness  of  methods  of  examination  and 
the  difficulty  of  fixing  a  standard  with  wide  enough  limitations  to 
include  all  normal  cases,  and  yet  of  sufficient  definiteness  to  be  a 
standard. 

Finally,  we  have  that  vague  group  of  symptoms,  sensory,  motor, 
and  secretory  combined,  which,  in  the  absence  of  any  definite  or 
tangible  demarcation,  has  been  called  "nervous  dyspepsia."  It 
includes  definite  feelings  of  distress,  pain  or  heaviness  in  the  epi- 
gastric region,  eructations,  anorexia,  gastric  torpor  rather  than 
marked  atony,  intervals  of  excess  of  acid  secretion,  and  an  associated 
intestinal  derangement,  with  almost  invariable  constipation. 

The  most  important  features  in  the  diagnosis  of  any  gastric 


662      deaver:  use  and  abuse  of  gastroenterostomy 

neurosis  is  the  eliciting  of  a  careful  history,  which  will  show  the 
general  neurasthenic  condition  of  the  patient.  The  presence  of 
a  manifest  general  nervous  breakdown  with  an  undoubted  neuras- 
thenia would  at  once  predispose  us  to  consider  any  gastric  symptoms 
present  as  but  local  signs  of  a  general  process.  Again,  this  run- 
down condition  may  be  a  secondary  neurasthenia,  due  to  a  primary 
lesion  which  underlies  both  it,  indirectly,  and  the  primary  condition 
of  the  stomach  most  directly.  A  patient  with  a  latent  but  not 
symptomless  gastric  ulcer  would  soon  show  gastric  symptoms, 
which  might  be  considered  nervous  in  origin,  as  well  as  a  general 
neurasthenic  condition,  due  to  his  sufferings. 

Carcinoma  in  its  early  stages  is  much  more  often  considered  as  a 
gastric  catarrh  or  nervous  dyspepsia  than  it  is  recognized.  Ano- 
rexia, followed  by  the  symptoms  of  a  vague  chronic  gastritis  or 
neurosis,  when  it  occurs  in  a  middle-aged  person,  is  a  condition 
which  should  excite  our  greatest  apprehension,  and  be  dismissed 
from  consideration  only  after  the  most  careful  examination  has  been 
made — after  the  case,  if  obstinate,  has  come  to  operation. 

Punctate  ulceration  of  the  stomach  mucosa  with  small,  early 
bleeding  points  may  involve  almost,  if  not  quite,  all  of  the  gastric 
mucosa.  In  the  absence  of  the  classical  signs  of  ulcer,  which  we 
often  have  in  this  condition,  the  hyperchlorhydria  present  has  often 
been  mistaken  for  the  main  lesion. 

It  has  always  been  my  opinion  that  in  very  many  of  the  cases  of 
vomiting  regarded  as  primary  neuroses  we  have  really  a  symptom 
only  of  some  lesion  in  or  oustide  of  the  stomach  which,  for  some 
reason  or  other,  we  have  been  unable  to  determine.  Vomiting  as 
a  pure  motor  neurosis  is  regarded  nowadays  as  far  less  frequent 
than  it  was  thirty  years  ago,  yet  we  occasionally  see  it. 

The  surgeon's  principal  duty  as  regards  the  true  neuroses  of  the 
stomach  is  to  recognize  them,  to  separate  them  from  secondary 
dyspeptic  conditions  due  to  lesions  which  perhaps  it  is  within  his 
province  to  treat.  I  regard  the  proposition  to  operate  on  these 
cases  for  the  mental  effect  upon  their  general  neurasthenic  or 
hysterical  condition  as  unsafe,  illogical,  and  as  setting  a  most  dan- 
gerous precedent. 

There  is  no  exception,  perhaps,  to  the  general  statement  that  gas- 
tric neuroses  per  se  are  not  within  the  province  of  the  surgeon. 
If  we  consider  gastric  atony  and  ptosis  as  really  neuroses,  when  they 
are  apparently  primary,  they  form  the  exception.  There  are  cer- 
tain of  these  cases  in  which  all  medical  and  general  treatment  is 
unavailing,  while  a  gastro-enterostomy  promptly  leads  to  recovery, 
by  furnishing  the  stomach  with  drainage,  which  by  its  own  force  it 
is  unable  to  secure.  In  ptosis  I  believe  that  gastro-enterostomy  is 
the  only  logical  procedure.  This  is  true  even  in  some  instances  in 
which  the  pylorus  is  entirely  patulous.    While  I  believe  that  an 


deaver:  use  and  abuse  of  gastroenterostomy  663 

occlusion  of  the  pylorus  is  the  main  indication  for  gastroenter- 
ostomy, I  do  not  think  it  is  the  only  one. 

To  make  a  gastro-enterostomy  upon  a  patient  with  gastric  neurosis 
pure  and  simple  is  nothing  short  of  a  catastrophe.  Within  the  past 
year  a  patient  came  under  my  observation  who  had  had  several  oper- 
ations performed,  the  last  of  which  was  a  gastro-enterostomy.  The 
patient,  a  typical  neurasthenic,  as  a  matter  of  course  was  not  only 
not  benefited  by  the  latter  procedure,  but  made  very  much  worse. 
After  having  her  under  my  care  for  a  number  of  days  I  determined 
to  restore  her  stomach  and  intestines  to  a  normal  condition,  minus  the 
amount  of  bowel  necessary  for  her  to  lose  in  order  to  cut  out  the 
portion  involved  in  the  anastomosis;  this  I  did,  with  closure  of  the 
stomach,  the  patient  being  markedly  benefited  thereby  for  a  time. 
I  have  recently  learned  that  she  is  vomiting  again  and  her  condition 
is  practically  the  same  as  before  the  first  operation.  There  could  be 
no  better  example  of  the  futility  of  operation  in  gastric  neuroses. 

Being  jealous  of  the  benefits  that  surgery  has  conferred  upon 
humanity,  not  the  least  of  which  are  in  this  field,  I  do  not  wish  to 
have  discredit  cast  upon  her  efforts  by  operations  performed  upon 
improper  indications.  It  is  with  some  trepidation,  however,  that  I 
advise  against  operation  in  gastric  neuroses,  simply  because  so 
many  cases  are  thus  incorrectly  diagnosticated  which  would  afford 
brilliant  surgical  cures.  In  giving  this  advice,  therefore,  it  is  with 
a  plea  for  more  careful  observation  to  rule  out  any  possibility  of  an 
organic  lesion  being  accountable  for  the  symptoms.  We  are  jus- 
tified in  considering  only  those  cases  as  neuroses  which  give  a  history 
clearly  indicating  other  neurotic  stigmas,  with  symptoms  that  vary 
greatly  without  apparent  cause,  or  as  the  result  of  emotional  states, 
and  which  give  to  careful  observation  no  clue  to  an  organic  lesion. 
Better  that  such  cases  should  come  to  exploration  occasionally  than 
to  miss  many  true  surgical  cases.  But  I  do  not  concur  in  the  advice 
to  operate  upon  these  cases  knowingly,  nor,  having  unwittingly 
explored  the  stomach  in  such  a  case,  to  make  a  gastro-enterostomy 
or  any  other  operation  in  the  absence  of  a  definite  physical  indication. 

In  conclusion,  it  is  fitting  for  me  to  say  that  every  surgeon  should 
first  be  a  physician.  The  surgeon  should  understand  disease,  its 
physical  signs,  and  its  differential  diagnosis.  The  surgeon  who  does 
not  possess  this  knowledge  is  not  in  a  position  to  advise  treatment. 
The  surgeon  should  not  be  the  mere  human  tool  of  the  physician. 
I  regret  to  say  that  surgeons  are  of  two  classes — the  surgeon  and  the 
operator;  the  combination  is  what  makes  the  true  surgeon.  It  is 
to  be  regretted  that  the  laity  too  often  regard  the  surgeon  as  the  last 
man  to  be  called  in.  How  often  their  distaste  for  the  surgeon  has 
been  the  cause  of  the  fatality! 


664 


bangs:  the  treatment  OF  GONORRHEA 


HAVE  WE  MADE  ANY  PROGRESS  IN  THE  TREATMENT 
OF  GONORRHOEA?1 

By  L.  Bolton  Bangs,  M.D., 

CONSULTING  SURGEON  TO  THE  BELLEVUE  AND  ST.   LUKE'S  HOSPITALS,   NEW  YORK. 

So  much  has  been  said  and  written  on  the  theme  of  gonorrhoea 
and  its  treatment  that  you  may  be  disposed  to  ask  why  I  should  have 
chosen  it  for  this  evening's  discussion.  The  answer  to  this  question 
is,  that  for  an  indefinite  time  the  impression  has  been  growing  into 
a  conviction  that  we  are  getting  better  results  than  formerly  in  the 
treatment  of  gonorrhoea.  Not  that  we  are  shortening  the  duration 
of  an  attack;  for,  although  in  some  cases  the  disease  can  be  promptly 
throttled,  its  duration  still  averages  from  four  to  six  weeks;  but 
(1)  we  are  now  able  to  mitigate  the  sufferings  of  the  first  or  acute 
period,  say  of  the  first  week.  (2)  We  believe  that  there  are 
fewer  complications,  and  a  diminished  liability  to  them;  as,  for 
instance,  to  posterior  urethritis  with  its  liability  to  inflammation 
of  the  contiguous  structures.  (3)  There  is  less  tendency  to 
become  chronic  and  to  the  development  of  that  formerly  frequent 
sequel  of  gonorrhoea,  stricture  of  the  urethra.  (4)  It  is  now  easier 
to  insure  the  patient's  attention  to  treatment,  for  there  is  a  wider 
and  better  understanding  of  the  danger  of  infection  by  latent  gonor- 
rhoea. 

You  will  admit  that  anything  relating  to  this  disease  continues  to 
be  of  great  importance;  for  apparently  there  is  no  lessening  in  the 
number  of  cases,  but,  on  the  contrary,  a  gradual  and  steady  increase 
in  their  number.  Dr.  Victor  C.  Pedersen,  who  is  in  charge  of  the 
Hudson  Street  House  of  Relief  on  the  west  side  of  the  city,  tells  me 
that  there  is  a  "  normal"  increase  in  the  number  of  the  cases  of 
gonorrhoea.  At  this  institution  there  are  from  7800  to  8000  new 
patients  per  annum,  and  from  60  per  cent,  to  70  per  cent,  of  these 
are  cases  of  acute  gonorrhoea.  Dr.  Swinburne,  on  duty  at  the  Good 
Samaritan  Hospital,  on  the  east  side  of  the  city,  informs  me  that  in 
this  hospital  there  are  from  50  per  cent,  to  60  per  cent,  of  new  cases 
of  acute  gonorrhoea  per  annum.  It  is  evident  that  as  yet  no  prop- 
aganda of  scientific  instruction  has  reached  this  stratum  of  society, 
and,  according  to  Morrow,  Julienne,  and  others,  the  general  morbidity 
in  women,  men,  and  children  as  a  result  of  gonorrhoea  is  so  great  as  to 
warrant  the  term  alarming;  and  at  all  events  it  is  sufficient  to  arouse 
within  us  the  wish  to  do  what  we  can  to  lessen  the  grave  scourge. 

Morrow  says:  "It  is  a  conservative  estimate  that  fully  one- 
eighth  of  all  human  disease  and  suffering  comes  from  this  source. 
Moreover,  the  incidence  of  these  diseases  falls  most  heavily  upon 

1  An  address  delivered  at  a  meeting  of  the  Society  of  the  Alumni  of  Bellevue  Hospital , 
New  York,  March  3,  1909. 


bangs:  the  treatment  of  gonorrhoea 


665 


the  young  during  the  most  active  and  productive  period  of  life.  It 
is  a  fact  worthy  of  consideration  that  every  year  in  this  country 
770,000  males  reach  the  age  of  early  maturity;  that  is,  they 
approach  the  danger  zone  of  initial  debauch.  It  may  be  affirmed 
that  under  existing  conditions  at  least  60  per  cent.,  or  over  450,000, 
of  these  young  men  will  some  time  during  life  become  infected  with 
venereal  disease,  if  the  experience  of  the  past  is  to  be  expected  as  a 
criterion  of  the  future.  Twenty  per  cent,  of  these  infections  will 
occur  before  their  twenty-first  year,  50  per  cent,  before  their  twenty- 
fifth  year,  and  more  than  80  per  cent,  before  they  pass  their  thirtieth 
year.  These  450,000  infections,  be  it  understood,  represent  the 
venereal  morbidity  incident  to  the  male  product  in  a  single  year. 
Each  succeeding  group  of  males  who  pass  the  sixteenth  year  furnishes 
its  quota  of  victims,  so  that  the  total  morbidity  from  this  constantly 
accumulative  growth  forms  an  immense  aggregate.  .  .  .  There 
is  abundant  statistical  evidence  to  show  that  80  per  cent,  of  the 
deaths  from  inflammatory  diseases  peculiar  to  women,  75  per  cent, 
of  all  special  surgical  operations  performed  on  women,  and  over 
60  per  cent,  of  all  the  work  done  by  specialists  in  diseases  of  women 
are  the  result  of  specific  infection.  In  addition,  50  per  cent,  or 
more  of  these  infected  women  are  rendered  absolutely  and  irre- 
mediably sterile,  and  many  are  condemned  to  life-long  invalidism. 
From  70  to  80  per  cent,  of  the  ophthalmia  which  blots  out  the  eyes 
of  babies,  and  15  to  25  per  cent,  of  all  blindness  is  caused  by  the 
gonococcus  infection." 

On  the  other  hand,  Dr.  E.  A.  Davis  and  Dr.  Gehring2  claim  that 
the  number  of  cases  of  ophthalmia  neonatorum  in  the  dispensaries 
is  diminishing,  because  of  better  understanding  of  the  care  of  the 
baby  at  birth. 

Now  the  question  naturally  arises,  are  these  impressions  as  to 
improvement  in  treatment  shared  by  other  observers?  And  will 
the  opinions  and  teachings  of  others  in  the  practice  of  genito- 
urinary surgery  deepen  or  efface  these  impressions?  Let  us  see 
what  answer  we  shall  get  from  authorities.  I  will  quote  freely  from 
the  literature  of  the  subject. 

1.  What  has  been  accomplished  in  relation  to  the  duration  of 
the  disease?  In  my  own  practice,  although  admitting  that  the 
majority  of  cases  last  from  four  to  six  weeks,  there  are  others  (more 
in  number  than  formerly),  especially  in  the  higher  social  strata, 
which  terminate  in  two  or  three  weeks.  But  there  is  an  interesting 
unanimity  of  opinion  on  the  part  of  authorities  that  the  disease 
takes  from  four  to  six  weeks  to  run  its  course  in  those  cases,  which 
do  not  become  chronic. 

For  example,  Watson  and  Cunningham3  define  "cure"  as  follows: 

2  Oral  communication. 

3  Diseases  and  Surgery  of  the  Genito-urinary  System,  1909. 


666 


bangs:  the  treatment  of  gonorrhoea 


"By  cure  we  mean  not  necessarily  the  cessation  of  the  discharge, 
but  its  non-recurrence  upon  omitting  the  treatment  and  upon  re- 
suming an  ordinary  manner  of  living. "  They  then  say:  "One 
frequently  hears  the  claim  that  gonorrhoea  can  be  cured  within  a 
week  or  ten  days,  or  at  least  a  fortnight.  Personally  we  have  no 
sense  of  shame  in  frankly  confessing  our  inability  to  accomplish 
such  results,  as  a  rule,  although  we  sometimes  succeed  in  so  doing. 
We  consider  ourselves  and  the  patient  fortunate  if  we  obtain  a  cure 
at  any  time  less  than  six  weeks."  R.  W.  Taylor4  states:  "In 
favorable  cases  a  cure  may  be  brought  about  in  four  to  six  weeks. 
Occasionally  some  patients  get  well  in  three  or  four  weeks."  White 
and  Martin5  state  that  the  "prognosis,  under  favorable  conditions, 
is  good  for  recovery  by  the  eighth  week;"  while  Greene  and  Brooks,6 
without  making  a  definite  statement  as  to  time,  think  that  "it  is 
better  to  postpone  the  active  local  treatment  of  urethritis  until  after 
the  acute  stage  is  passed  and  the  discharge  first  becomes  muco- 
purulent. This  is  generally  about  the  fourth  to  the  sixth  week 
after  the  onset  of  the  disease."  Hyde  and  Montgomery  are  even 
less  sanguine  and  consider  that  "usually  a  first  attack,  with  favor- 
able circumstances  and  good  treatment,  recovers  in  from  five  to 
eight  weeks."  Morton  also  states  that  "the  percentage  of  recoveries 
in  two  or  three  weeks  is  small,  and  that  the  usual  duration  is  six 
weeks."  Finger  and  Casper,  representative  of  the  Germans,  are 
unqualifiedly  pessimistic,  and  while  admitting  that  the  disease  ends 
in  from  five  to  six  weeks,  state  that  the  prognosis  is  doubtful.  On 
the  other  hand,  Keyes,  Senior  and  Junior7  are  decidedly  optimistic, 
and  quite  positively  state  the  duration  to  be  "untreated,  six  weeks 
or  more;  but  curable  within  two  or  three  weeks  by  the  irrigation 
method." 

2.  In  regard  to  the  mitigation  of  symptoms,  although  this  amelio- 
ration may  be  inferred  from  such  statements  as  "in  from  four  to  ten 
days  all  obvious  discharge  ceases,"  etc.,  I  find  very  few  definite 
statements;  but  as  a  result  of  my  experience  it  may  be  confidently 
said  that  prompt  treatment  by  one  of  the  albuminoid  preparations 
of  silver  (organic  compounds),  together  with  judicious  hygienic 
measures  resolutely  carried  out,  will  reduce  the  activity  of  the  infec- 
tion, proportionately  subdue  the  inflammatory  symptoms,  and 
possibly  modify  the  whole  course  of  the  attack. 

3.  In  regard  to  the  complications  of  gonorrhoea,  we  are  met  by 
contradictory  statements  and  confusion  of  opinions.    A  study  of 
systematic  writers,  in  collaboration  with  Dr.  Edward  Preble,  shows 
that  the  percentage  of  frequency  of  complications  varies  so  much 
with  individual  experience  that  it  is  impossible  to  prove  by  the 

4  Genito-urinary  and  Venereal  Diseases,  1900. 

5  Genito-urinary  Diseases,  1907. 

fi  Diseases  of  the  Genito-urinary  Organs  and  the  Kidneys,  1908. 

7  Surgical  Diseases  of  the  Genito-urinary  Organs,  1903,  pp.  119  to  124. 


bangs:  the  treatment  of  gonorrhoea 


667 


evidence  that  complications  were  any  more  prevalent  under  old 
methods  than  at  the  present  time.  So  far  as  blood  infections  and 
remote  metastases  are  concerned,  there  are  virtually  no  statistics 
given,  while  for  epididymitis,  cystitis,  prostatitis,  spermocystitis, 
etc.,  the  figures  show  every  variation.  In  AVossidlow's  monograph 
(1903)  the  conclusions  agree  with  those  of  other  writers;  namely, 
that  acute  posterior  urethritis,  according  to  the  majority,  is  an  all 
but  universal  sequel,  while  other  writers  find  it  much  less  frequent. 
Statistics  of  acute  prostatitis  vary  from  3  to  70  per  cent.;  sperma- 
tocystitis  is  said  by  some  to  be  very  rare,  while  others  make  it 
extremely  common.  There  seem  to  be  no  figures  for  cystitis,  as  it 
is  too  readily  confounded  with  posterior  urethritis  and  prostatitis. 

Uhle  and  McKinney8  cite  the  combined  statistics  of  Rollet, 
Tarnowsky,  Jullien,  and  Finger — 11,972  cases  of  gonorrhoea,  with 
2244  cases  of  epididymitis,  or  18.7  per  cent.  The  authors'  own 
material  represented  16  per  cent.  Neuberger0  quotes  Jordan,  of 
Moscow,  who  compiled  statistics  which  show  that  30  per  cent,  of 
gonorrhceal  patients  suffer  from  epididymitis  in  hospital  practice. 
In  dispensaries  and  private  practice  the  proportion,  according  to 
Jordan,  varies  from  7  to  17.3  per  cent.  The  figures  for  dispensary 
patients  are  11.7,  but  if  the  history  of  the  cases  was  taken  into 
account  the  proportion  increased  to  27.8  per  cent.  The  joint 
testimony  of  several  authors  is  to  the  effect  that  from  80  to  90  per 
cent,  of  gonorrhceal  patients  develop  posterior  urethritis.  The 
author  gives  a  series  of  200  cases  treated  in  the  early  period  with 
protargol  injections  followed  by  Janet  irrigations  when  the  subacute 
stage  was  nearly  over,  with  but  six  cases  of  epididymitis,  or  3  per 
cent.  Neisser  does  not  use  irrigations  in  the  acute  period,  relying 
upon  injections  of  the  prolonged  type.  His  proportion  of  epididy- 
mitis was  9  per  cent.  Tauska10  gives  an  analysis  of  17  statistics, 
making  the  percentage  vary  from  3.2  to  29.2  per  cent.,  the  average 
being  15  per  cent.  His  material  was  674  cases  of  gonorrhoea,  75, 
or  11.1  per  cent.,  having  epididymitis  on  admission,  while  18  cases 
gave  a  history  of  the  complication.  The  total  of  93  cases  was 
13.8  per  cent. 

Lewin  and  Bohn11  present  a  series  of  personal  statistics  on  acute 
spermatocystitis;  the  article  also  gives  incidentally  the  relative 
frequency  and  relations  of  posterior  urethritis,  prostatitis,  epididy- 
mitis, and  spermatocystitis.  The  authors  have  carefully  studied 
1000  cases  of  gonorrhoea  from  this  point  of  view.  Their  figures 
appear  to  show  that  if  posterior  urethritis  can  be  prevented  these 

8  The  Study  of  Two  Hundred  and  Sixty-four  Cases  of  Gonorrhceal  Epididymitis,  New 
York  Medical  Journal,  1907. 

9  The  Prevention  of  Epididymitis  and  the  Method  of  Treatment  of  Gonorrhcea  in.£he 
Acute  and  Subacute  Stages,  Dermatol.  Zeitschrift,  1907,  xiv,  14.  . 

10  Pathology  and  Statistics  of  Epididymitis,  Arch.  f.  Dermatol,  u.  Syph.,  1908,  89,  255/ 
»J  Zeitschrift  f.  Urologie,  1909,  iii,  1. 


668 


bangs:  the  treatment  of  gonorrhoea 


complications  hardly  occur;  also  that  early  recognition  and  prompt 
treatment  of  spermatocystitis  should  often  prevent  epididymitis.  Of 
the  1000  cases,  629  had  posterior  urethritis,  that  is,  63  per  cent.,  and 
of  this  number  the  prostate  alone  was  inflamed  in  385  (61  per  cent.) ; 
the  seminal  vesicles  (one  or  both)  in  38  (6  per  cent.),  and  the  pros- 
tate and  vesicles  together  in  180  (29  per  cent.).  Added  together,  this 
makes  565  cases  of  prostatitis  (about  90  per  cent.)  and  218  cases 
of  spermatocystitis  (nearly  35  per  cent.).  Of  the  218  cases  of 
spermatocystitis,  139  were  bilateral,  79  unilateral,  47  on  the  left  and 
32  on  the  right  side.  In  the  1000  cases  of  gonorrhoea  were  124 
recent  cases  of  epididymitis  (12.4  per  cent.).  With  this  number 
were  107  cases  of  prostatitis,  42  isolated  and  65  associated  with 
spermatocystitis.  There  were  76  cases  of  spermatocystitis,  65 
associated  with  prostatitis,  and  11  isolated.  While  the  authors  are 
not  entirely  clear  on  the  matter,  they  give  the  impression  that  sper- 
matocystitis is  responsible  for  many  cases  of  subsequent  epididy- 
mitis. Under  the  head  of  treatment,  as  already  said,  they  agree 
that  early  recognition  and  treatment  of  it  will  prevent  epididymitis. 
Of  the  218  cases  of  spermatocystitis,  156  were  of  the  simple 
superficial  or  catarrhal  type,  50  were  examples  of  chronic  inflamma- 
tion with  obliteration  fibrosis,  and  9  were  instances  of  empyema. 
Three  cases  were  not  accounted  for.  Of  the  371  cases  of  anterior 
urethritis  alone,  there  were  but  4  with  complications,  all  cases  of 
prostatitis.  In  this  article  there  are  two  significant  statements: 
(1)  That  if  posterior  urethritis  can  be  prevented,  complications 
hardly  occur;  and  (2)  that  early  recognition  and  treatment  of 
spermatocystitis  will  prevent  epididymitis.  These  are  in  accord 
with  and  strengthen  my  first  proposition. 

4.  Coming  now  to  the  question  of  treatment,  it  is  interesting  to 
note  that  the  effort  of  most  teachers  is  to  simplify  it,  employing 
fewer  remedies  and  a  more  expert  procedure.  The  methods  of 
thirty  years  ago  show  an  uncertainty  and  complexity  that  does  not 
exist  today.  Not  only  is  therapeutics  more  effective,  but  pathology 
has  been  very  much  simplified.  Since  Neisser's  discovery  of  the 
gonococcus  we  have  had  a  definite  means  of  diagnosis,  and  also  a 
definite  means  of  prognosis  of  the  acute  stage.  Yet,  as  already 
said,  no  matter  what  be  the  form  of  treatment,  the  average  duration 
of  the  acute  stage  of  the  disease  remains  from  four  to  six  weeks. 
Notwithstanding  our  better  understanding  of  the  pathology  of  the 
urethra  and  of  the  cause  of  the  disease,  nature  still  takes  her  own 
time  to  remedy  the  results  of  infection,  and  to  restore  to  a  normal 
condition,  or  as  near  normal  as  possible,  the  mucous  membrane, 
which  has  been  devastated.  Whether  the  treatment  has  been 
expectant,  or  by  irrigation,  or  by  hand-injection,  or  by  the  combina- 
tion of  the  expectant  and  any  other  method,  it  seems  to  take  just 
about  so  long  for  a  new  mucous  membrane  to  be  formed.  The 
inference  is  that  our  methods  should  be  unirritating,  and  adapted  to 


bangs:  the  treatment  of  gonorrhoea  669 

the  indications  as  the  latter  arise.  In  1876  Mr.  J.  L.  Milton,  of 
London,  compiled  a  list  of  63  medicaments  used  for  urethral  injec- 
tion, for  some  of  which  extraordinary  virtues  were  claimed ;  such,  for 
instance,  as  the  cure  of  recent  infections  in  from  one  to  four  days, 
with  only  two  failures  in  64  cases!  But  on  the  modern  definiteness 
and  simpler  therapeutics  Watson  and  Cunningham  may  be  quoted. 
They  say:  "  We  do  not  propose  to  let  ourselves  stray  from  the  narrow 
limits  defined  by  the  efficacious  remedies  which  have  earned  a  right 
to  be  seriously  accepted  as  having  an  established  value.  Those 
which  are  worthy  to  be  thus  classed  are  the  following:  the  silver 
preparations,  protargol,  argyrol,  and  nitrate  of  silver;  permanganate 
of  potash,  and  the  astringent  remedies,  zinc  and  lead.  The  first 
three  and  permanganate  of  potash  aim  at  the  destruction  of  the 
gonococcus,  or  at  inhibiting  its  activity  to  the  degree  that  the  ure- 
thral membrane  shall  have  the  power  to  repair  sufficiently  to  repel 
its  further  attacks.  The  nitrate  is  of  special  value  in  the  more 
chronic  stage  of  the  disease." 

Notwithstanding  the  modern  attempt  at  simplification,  there  is 
diversity  of  opinion  as  to  method.  In  illustration  I  may  make  the 
following  citations:  Keyes  and  Keyes,  Jr.,12  say  positively  that  in 
the  previous  edition  Keyes,  Sr.,  has  not  advocated  irrigation,  but 
that  Dr.  Chetwood's  modification  of  Janet's  method  has  given 
results  never  before  obtained  in  thirty-five  years  of  practice.  The 
results  are  so  much  better  that  he  recognizes  their  obvious 
superiority,  giving  Dr.  Chetwood  the  whole  credit. 

R.  W.  Taylor13  recommends  zinc  injections  almost  at  the  onset. 
Only  in  the  declining  stage  does  he  recommend  irrigation.  In  the 
very  acute  early  stage,  when  the  question  of  local  treatment  is  a 
delicate  one,  he  mentions  weak  permanganate  and  protargol  as 
antiseptics,  stating  that  they  benefit  but  do  not  cure.  He  seems  to 
imply  that  they  may  prevent  posterior  urethritis,  but  astringents  and 
capsules  are  his  main  remedy.  Under  the  paragraph  entitled 
"Fads  in  the  Treatment  of  Gonorrhoea"  he  scores  the  heroic  use 
of  antiseptics  and  ridicules  the  claims  of  rapid  cure.  There  may 
be  an  apparent  rapid  improvement,  but  the  discharge  is  not  arrested 
and  the  mucosa  become  succulent,  so  much  so  that  urination  is 
hindered  and  bladder  irritation  develops.  Patients  seldom  try  this 
treatment  a  second  time.  He  appears  to  discredit  the  apparent 
cures  by  Janet's  method. 

Marshall14  advocates  protargol  followed  by  astringent  injections 
as  preferable  to  irrigations,  which  are  irksome.  He  gives  no  local 
treatment  if  the  parts  are  cedematous.  The  treatment  of  chronic 
urethritis  is  overdone,  chiefly  because  of  the  introduction  of  the 


12  Surgical  Diseases  of  the  Genito-urinary  Organs,  1903. 

13  Genito-urinary  and  Veneral  Diseases. 

14  Syphilis  and  Gonorrhoea,  1904. 


670 


bangs:  the  treatment  OF  GONORRHEA 


urethroscope.  Patients  expect  this  to  be  used  in  all  cases,  and  it  is 
often  meddlesome.  Instrumentation  should  be  avoided  except  in 
very  chronic  cases. 

Hyde  and  Montgomery  (1900),  unlike  most  writers,  have  a  para- 
graph on  prognosis.  They  regard  local  treatment  as  particularly 
suitable  for  the  stage  of  decline.  Pus  is  a  contraindication.  A 
theory  that  gonococci  are  to  be  killed  is  responsible  for  much 
permanent  damage.  Weak  astringents,  if  any,  should  be  used.  It 
is  best  to  reserve  injections  for  a  patient  who  has  had  complications, 
epididymitis,  cystitis,  etc. 

Fuller15  speaks  well  of  the  newer  silver  preparations;  if  used  very 
early  in  the  disease  they  may  prove  of  much  value.  Argonin,  as 
introduced  by  Jadassohn  in  1895,  he  has  used  considerably. 
Protargol  came  out  later.  It  gave  good  results  in  private  practice 
where  cases  are  seen  early.  Janet's  method  is  given  exhaustively, 
but  the  author  believes  it  causes  spermatocystitis,  and  hesitates  to 
recommend  it.  He  evidently  prefers  injections  of  the  mild  anti- 
septics when  the  case  can  be  controlled.  Astringents  are  never  to 
be  used  until  the  declining  stage,  and  then  not  over  twice  daily. 

Morton10  forbids  the  use  of  the  astringents  before  the  declining 
stage.  Janet's  method  will  check  the  purulent  discharge  in  eight 
days  in  most  cases,  but  spontaneous  relapses  occur  even  in  the 
midst  of  treatment,  and  they  are  often  repeated  several  times.  A 
thin  discharge  for  weeks  may  persist,  so  that  ultimate  recovery  is 
not  hastened.  This  method  appears  to  prevent  posterior  pros- 
tatitis. It  must  be  begun  early  to  be  effective.  The  expense, 
trouble,  and  inconvenience  are  against  it,  and  the  author  does  not 
appear  to  advocate  Janet's  method  as  a  routine  procedure;  he 
probably  prefers  for  this  purpose  the  use  of  silver  solutions  as  anti- 
septics. Treatment  with  protargol,  0.25  to  1  per  cent.,  causes  im- 
provement in  a  few  days;  the  acute  symptoms  subside  directly. 
The  protargol  is  now  given  in  greater  concentration,  and  after  a 
few  more  days  the  discharge  ceases;  but  if  the  protargol  is  stopped 
a  relapse  occurs.  The  percentage  recovering  in  two  or  three  weeks 
is  small;  in  most  cases  five  or  six  weeks  are  required. 

Lydston,17  in  assailing  specific  and  rapid  cures  for  gonorrhoea,  says 
that  Janet's  method  should  not  be  placed  arbitrarily  in  this  class. 
In  practice  it  is  very  rare  for  a  case  to  be  treated  rationally,  because 
both  patient  and  physician  underrate  the  possibilities  of  the  disease. 
Personal  experience  of  cases  is  too  often  based  upon  simple,  mild 
cases.  Local  injection  is  the  most  available  treatment;  irrigation 
requires  time  and  money  at  best.  Proper  injections  prevent  stric- 
tures and  complications.  There  is  still  a  popular  prejudice  against 
injections;  patients  are  wont  to  blame  them  for  complications,  and 

15  Diseases  of  the  Genitourinary  System,  1900. 
18  Genito-urinary  Diseases,  1902. 

17  Surgical  Diseases  of  the  Genito-urinary  Tract,  1904. 


bangs:  the  treatment  of  gonorrhoea 


671 


some  practitioners,  by  censuring  the  injection  treatment,  conspire 
with  the  prejudice.  Lydston  believes  in  the  modern  organic  solu- 
tions of  silver  for  their  bactericidal  action,  preferring  them  to  astrin- 
gents, which  may  impair  the  defensive  activity  of  the  tissues. 
However,  he  combines  ordinary  antiseptics  and  astringents. 

Baumann  has  a  good  chapter  on  prognosis.  This  in  pure 
gonorrheal  affections  is  favorable.  In  subacute  and  chronic  forms 
it  is  conditional  on  several  factors — duration,  complications,  treat- 
ment. No  method  of  treatment  is  free  from  relapses.  Complica- 
tions are  more  frequent  with  chronic  gonorrhoea.  The  author 
believes  nitrate  of  silver  to  be  the  best  local  remedy.  Germicides 
and  antiseptics  always  irritate;  the  more  antiseptic  the  more  irri- 
tant. For  irrigation  he  uses  permanganate  of  potash,  1  to  2000  to 
1  to  20,000,  and  this  treatment  is  not  contra-indicated  even  in  the 
early  stages— in  fact,  he  finds  it  the  most  beneficial  at  this  time. 
He  also  irrigates  with  nitrate  of  silver  and  zinc  sulphate  in  weak 
concentration. 

Greene  and  Brooks  regard  posterior  urethritis  as  universally 
present.  They  use  no  local  measures  until  the  mucopurulent 
stage  is  reached.  They  object  to  astringents  on  theoretical  grounds. 
Mild  antiseptics  will  not  injure  outright,  but  are  not  recommended. 
Directions  however,  are  given  for  those  who  wish  to  employ  them. 
Then  begins  the  treatment  recommended  by  the  authors;  it  is  made 
to  the  posterior  as  well  as  to  the  anterior  urethra,  and  irrigation 
with  silver  nitrate  follows. 

Von  Zeissl,18  like  Finger,  quotes  Ricord's  aphorism:  "We  know 
when  the  gonorrhoea  begins;  we  know  nothing  as  to  when  it  will 
end."  Many  factors  affect  the  prognosis  in  individual  cases.  Astley 
Cooper's  dictum  is  fully  borne  out  today:  "In  many  cases,  despite 
all  remedies,  the  malady  lasts  so  long  that  it  is  a  reproach  to  our  art." 
Under  "  treatment"  he  speaks  of  the  difficulty  of  controlling  private 
patients,  pointing  out  that  they  are  exposed  to  many  prejudicial 
circumstances  to  which  a  hospital  patient  is  not.  Zeissl  laments  that 
the  discovery  of  the  gonococcus  has  not  helped  us  in  the  treatment. 
Modern  antiseptics,  he  says,  give  him  no  better  results  than  do  the 
older  remedies.  However,  he  washes  out  the  anterior  urethra  with 
a  soft  catheter  and  a  permanganate  solution.  He  does  this  from 
the  start,  unless  oedema  and  lymphangitis  are  present.  Protargol 
may  be  substituted  for  the  permanganate.  He  also  recommends 
Janet's  method  as  a  later  resource.  He  also  uses  ordinary  injec- 
tions at  short  intervals. 

Finger  seems  to  be  decidedly  pessimistic,  and  apparently  does 
not  believe  that  our  methods  show  any  superiority  over  former  ones. 
On  the  other  hand,  he  does  not  assert  the  contrary.  He  goes  very 
thoroughly  into  the  history  of  the  treatment,  and  finds  that  many  of 

18  Frisch  and  Zuckerkandl's  Handb.  der  Urologie,  1906,  111. 


672 


bangs:  the  treatment  of  gonorrhoea 


our  modern  resources  are  not  really  new.  He  finds  syringes  two 
hundred  years  ago  differing  in  no  wise  from  those  of  today.  He  also 
describes  the  great  activity  of  the  specialists  of  a  generation  ago  in 
regard  to  the  problem  of  treatment.  He  believes  in  weak  protargol 
injections  from  the  onset,  unless  cedematous  swelling,  bloody  pus, 
and  phymosis  or  paraphymosis  are  present.  But  as  to  the  uncertain 
cure  and  its  complications  he  seems  to  believe  that  the  disease  is 
the  same  old  unknown  quantity  it  was  at  the  dawn  of  scientific 
medicine. 

Wassidlow  writes  in  a  less  pessimistic  vein  than  Finger,  but  no- 
where does  he  state  or  imply  that  our  knowledge  has  progressed  in 
recent  years.  Neither  is  the  contrary  statement  made  or  implied. 
In  a  new  edition  of  his  book,  Casper  seems  to  be  as  pessimistic 
as  Finger.  Under  "prognosis"  he  states  that  it  is  doubtful  if  the 
majority  of  cases  do  not  become  chronic;  while  in  the  chronic  stage 
excesses  of  any  kind  may  set  up  acute  exacerbations,  with  all  the 
attending  dangers  of  complications. 

Quite  a  number  of  writers,  however,  record  their  belief  that  we 
get  better  results  than  formerly.  Janet,  in  his  latest  article  (1907), 
appears  to  take  a  somewhat  similar  view.  On  the  other  hand,  all 
of  these  continental  experts  who  have  been  authorities  for  many 
years,  dating  back  to  pre-irrigation  days,  do  not  commit  themselves. 

In  a  very  interesting  article,  Streiff19  shows  that  irrigation  is  by 
no  means  a  new  resource.  Morgan,  of  Dublin,  employed  it  in 
1869;  Durham  (Guy's  Hospital)  in  1870;  Windsor,  of  Manchester, 
England,  in  1871,  using  permanganate  1  to  1000;  Reginald  Harrison 
in  1880;  Holbrook  Curtis  in  1883;  Halstead  and  Van  der  Poel  in  1886; 
Brewer  in  1887,  and  Reverdin  in  1892;  all  of  them  preceding  Janet; 
and  even  earlier  than  they  was  Serra,  who  used  irrigation  of  plain 
water  in  1831.  All  of  these  pioneers  irrigated  the  penile  urethra 
alone.  Another  series  of  men  irrigated  the  bladder  and  incidentally 
the  posterior  urethra:  Cloquer  (date  not  given),  Diday  in  1839, 
Reliquei  in  1871,  Bertholle  in  1877,  and  others.  Janet,  however, 
originated  modern  urethrovesical  irrigation,  and  also  the  theory 
that  it  cured  by  producing  serous  reaction  and  preventing  the  deep 
proliferation  of  gonococci.  The  author  regards  Janet's  method 
as  a  logical  development  of  bacteriology  and  antisepsis. 

Janet's  technique  has  been  modified  in  various  ways,  and  a  great 
number  of  substances  have  been  substituted  for  permanganate. 
In  France  nearly  all  surgeons  and  specialists  use  the  irrigation  in 
some  form.  They  wait  for  the  subsidence  of  the  inflammatory 
phenomena.  Irrigation  has  some  enemies  who  do  not  believe  in 
exposing  the  bladder  to  possible  infection,  and  who  rely  upon  in- 
jections and  balsamics. 

Streiff  says  nothing  whatever  as  to  the  superiority  of  modern 


19  Old  and  New  Treatment  of  Urethritis,  These  de  Paris,  1908. 


bangs:  the  treatment  of  gonorrhoea 


673 


measures.  A  century  ago,  or  thereabouts,  balsamics  had  superseded 
local  treatment.  The  latter  returned  into  vogue,  but  not  until  the 
discovery  of  the  gonococcus  and  antisepsis  did  it  receive  its  modern 
endorsement.  Streiff  claims  that  the  modern  treatment  of  urethritis, 
including  lavage,  instillation,  use  of  the  endoscope,  ointments, 
sounds,  massage,  etc.,  is  entirely  surgical  in  its  tendency. 

My  own  recollection  of  what  may  be  termed  the  era  of  irrigations 
in  its  different  stages  is  still  vivid.  There  was  also  an  era  of  nozzles 
for  insertion  into  the  meatus  urinarius.  Many  were  the  zealous 
experimenters.  Everybody  devised  or  modified  a  nozzle;  and 
every  nozzle  was  provided  with  both  an  inlet  and  an  outlet  tube,  in 
order  to  regulate  within  the  urethra  the  exact  pressure  of  the  irri- 
gating fluid.  We  also  "felt  our  way"  with  the  strength  of  the 
germicide,  in  order  to  obtain  an  unirritating  and  yet  efficient  solu- 
tion. At  that  epoch  the  bichloride  of  mercury  was  an  efficient 
germicide  when  applied  in  proper  solution  to  external  wounds; 
would  it  not  be  equally  efficient  in  gonorrhceal  infection?  Acting 
on  this  theory,  I  made  an  experiment  at  the  City  Hospital.  I  irri- 
gated a  considerable  number  of  cases  with  bichloride  of  mercury, 
the  solutions  beginning  with  a  strength  of  1  to  6000.  Any  one  who 
knows  the  irritating  effect  of  that  solution  can  imagine  the  warmth 
of  the  reception  I  received  from  the  patients  when  I  made  my  next 
visit  to  the  hospital.  The  same  experimentation  was  taking  place 
at  the  Vanderbilt  clinic  and  at  the  Outdoor  Department  of  Roose- 
velt Hospital.  The  result  of  our  combined  experience  and  of  our 
patients'  tribulations  was  to  reduce  the  solution  to  its  proper  strength, 
1  to  20,000  or  1  to  30,000.  Other  substances,  such  as  boric  acid, 
hydrastis,  methylene  blue,  and  permanganate  of  potassium  were 
also  experimented  with. 

The  house  surgeons  to  a  man  were  enthusiastic  over  the  irriga- 
tion treatment,  and  were  eager  to  employ  it  in  each  and  every  case. 
When  they  asked  me  what  antiseptics  they  should  use,  I  said, 
"Whichever  you  please."  And  now  happened  a  curious  thing,  to 
wit,  that  their  choice  seemed  to  be  determined  in  every  case  by 
the  complexions  of  the  house  surgeons.  I  will  not  say  post,  ergo 
'propter,  but,  as  a  matter  of  fact,  all  the  blond  men  chose  to  experi- 
ment with  plain  white  solutions  or  with  methylene  blue,  while  the 
brunette  men  invariably  treated  their  suffering  patients  with  the  red 
permanganate  of  potassium.  I  leave  the  explanation  of  this  to  the 
metaphysicians. 

My  own  conclusions  in  regard  to  the  irrigation  method  were  that 
it  did  not  readily  control  the  symptoms,  but,  on  the  contrary,  that  it 
was  even  liable  to  aggravate  them.  In  many  cases  of  acute  gonor- 
rhoea the  patients  can  hardly  tolerate  their  own  urine  passing  through 
the  urethera;  therefore  the  introduction  from  without  of  a  fluid 
which,  even  with  the  most  watchful  care,  may  overdistend  the  canal, 
is  liable  to  cause  traumatisms  and  aggravate  the  conditions.  Fur- 


674 


bangs:  the  treatment  op  gonorrhoea 


thermore,  as  time  went  on  I  became  convinced  that  these  irrigations 
not  only  did  not  shorten  nor  mitigate  the  attack,  but  that  posterior 
urethritis  was  more  prevalent,  and  that  therefore  inflammation  of  the 
contiguous  structures,  the  prostate,  the  epididymis,  etc.,  was  likelier 
to  occur.  Moreover,  the  irrigations  were  inconvenient,  they  were 
sloppy,  and  because  of  the  time  required  were  difficult  to  carry  out. 
Consequently,  for  acute  gonorrhoea  a  change  was  made  from  that 
method  to  the  one  I  now  prefer.  In  chronic  states  irrigations  may 
have  their  place;  but  even  then  only  in  exceptional  cases. 

There  is  a  method  called  by  the  Germans  the  "  provocative 
method."  Zieler,20  chief  of  Neisser's  clinic  at  Breslau,  who  evi- 
dently represents  the  opinion  of  many  of  his  colleagues,  believes 
that  whatever  cures  gonorrhoea  can  do  so  only  by  exciting  hyperemia 
and  serous  transudation.  The  "inflammatory  serum/'  as  he  terms 
it,  is  fatal  to  the  deep  proliferation  of  gonococci,  which  tend  to 
return  to  the  surface,  where  also  many  have  been  present  from  the 
beginning.  In  these  more  exposed  situations  they  may  be  destroyed 
by  antiseptics.  The  benefits  of  irrigation  he  attributes  solely  to  the 
hyperemia  set  up  mechanically,  not  at  all  to  the  permanganates. 
Protargol,  argyrol,  etc.,  are  both  hyperemizing  and  antiseptic,  hence 
the  good  results  from  their  use.  The  old-fashioned  astringents  are 
contra-indicated  because  they  antagonize  the  hyperemic  tendency 
and  permit  the  deep  proliferation  of  gonococci. 

German  physicians  use  the  expression  "provocative  treatment" 
for  the  use  of  mechanical  or  chemical  irritants  intended  to  cause 
hyperemia,  transudation,  and  destruction  of  gonococci.  A  writer 
having  termed  Dr.  Carl  Alexander's  (Breslau)  hydrogen  peroxide 
treatment  a  "provocative"  measure,  the  latter  replies,21  stating  that 
his  (1  per  cent.)  injection  or  irrigation  does  not  belong  under  this 
head.  He  uses  it  to  oxidize  and  destroy  the  gonotoxin.  Further, 
the  liberation  of  gas  in  the  urethra  exerts  a  mechanical  action  on 
foreign  material,  but  not  an  irritating  one.  He  regards  his  pro- 
cedure as  an  addition  to  our  resources;  if  it  fails  now  and  then,  so 
do  all  methods.  My  own  experience  with  hydrogen  peroxide  was 
not  at  all  satisfactory;  though  it  was  not  used  by  irrigation,  which 
I  agree  with  Kreissl22  is  a  step  backward,  and  gives  poor  results, 
tending  to  complications  and  chronicity.  With  the  advent  of  the 
albuminoid  salts  of  silver,  we  have  had  at  our  disposal  better 
means  of  controlling  the  infection.  Especially  if  used  in  the  early 
stages  of  the  disease,  they  will,  in  a  large  proportion  of  the  cases, 
modify  its  progress  and  lessen  the  liability  to  complications.  Their 
use  by  the  hand-injection  method,  followed  by  such  other  means 
as  may  be  indicated  in  the  later  stages  of  the  malady,  will  meet  all 
the  requirements.    The  salts  of  silver  are  well  under  control;  they 

2°  Munch,  med.  Woch.,  1907,  305. 

21  Zeitschrift  f.  Urologie,  1909,  iii,  1. 

22  Urogenital  Therapeutics,  Chicago,  1908. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


675 


can  be  used  in  the  most  intolerant  urethra  without  aggravating  the 
patient's  condition,  and  they  can  be  placed  in  the  hands  of  the 
patient  himself.  But  it  must  not  be  overlooked  that  the  latter  must 
also  be  treated.  Doubtless  you  will  think  it  a  mere  truism  to  say 
that  a  patient's  habits,  social  condition,  etc.,  affect  his  vital  processes.  \ 
But  we  must  take  advantage  of  whatever  physiology  can  do  to  limit 
the  supply  of  pabulum  to  the  infection  and  assist  in  strengthening 
the  resistance  of  the  tissue,  and  therefore  it  is  as  important  to  con- 
sider the  patient's  environment  as  to  give  him  local  treatment. 

To  me  a  very  important  fact  is  that  the  human  urethra  is  now 
looked  upon  with  what  might  be  termed  greater  respect.  This  is 
not  merely  a  speculative  statement.  It  has  a  practical  application. 
The  old-time,  coarser  point  of  view,  that  the  urethra  was  a  mere 
"  water  pipe,"  and  that  if  an  individual  subjected  himself  to  condi- 
tions which  infected  this  conduit  he  was  the  victim  of  his  own  folly, 
and,  to  use  the  common  phrase,  "it  served  him  right."  This  view 
naturally  tended  to  coarse  and  unsympathetic  treatment.  But  it 
is  now  recognized  that  the  uerthra  is  a  delicate,  highly  endowed 
organ,  susceptible  to  grave  local  damage,  and  that  its  infection  may 
be  propagated  to  distant,  even  to  vital  organs,  and  to  innocent 
persons.  Based  upon  this,  together  with  a  knowledge  of  the  specific 
cause  of  the  disease  our  methods  have  become  more  definite,  and  our 
technique  more  delicate  and  gentle.  Therefore  there  is  ground  for 
the  statement  that  the  average  case  shows  less  tendency  to  become 
chronic;  and  with  our  ability  to  inhibit  the  activity  of  the  infection 
when  the  case  is  seen  early  there  is  less  likely  to  be  a  posterior 
urethritis  and,  therefore,  less  liability  to  infection  of  the  contiguous 
structures. 

The  subject  is  a  large  one,  and  much  remains  to  be  accomplished, 
yet,  notwithstanding  the  dubious  tone  of  the  literature  which  I  have 
tried  to  review  I  am  satisfied  that  real  progress  has  been  made  in 
the  treatment  of  gonorrhoea. 


HELMINTHIASIS  IN  CHILDREN. 

By  Oscar  M.  Schloss,  M.D., 

ASSISTANT   TO   THE    CHAIR    OF    PEDIATRICS   IN   THE    NEW  YORK    UNIVERSITY  AND  BELLEVUE 
HOSPITAL  MEDICAL  COLLEGE;   ASSISTANT  VISITING  PHYSICIAN  TO  THE  OUT- 
PATIENT DEPARTMENT   OF  THE   BABIES'  HOSPITAL,  NEW  YORK. 

The  study  which  it  is  the  object  of  this  paper  to  record  was 
undertaken  in  the  effort  to  determine:  (1)  The  frequency  with  which 
children  between  the  ages  of  two  and  twelve  years  harbor  intestinal 
worms;  (2)  the  species  of  parasites  harbored  and  the  relative  frequency 
of  their  occurrence;  (3)  the  number  of  cases  in  which  the  common 


676 


SCHLOSSI  HELMINTHIASIS  IN  CHILDREN 


intestinal  worms  are  responsible  for  symptoms,  and  the  nature  of 
the  symptoms  produced;  and  (4)  the  occurrence  and  significance 
of  eosinophilia  in  infections  with  intestinal  worms.  These  investi- 
gations were  based  on  the  discovery  of  intestinal  worms,  their  parts, 
or  their  ova  in  the  feces.  Whenever  possible,  the  parasite  was 
obtained  after  treatment,  and  in  positive  cases  the  blood  was  ex- 
amined to  determine  the  percentage  of  hemoglobin  and  the  per- 
centage of  the  eosinophile  cells.  The  technique  used  in  making 
the  examinations  will  be  given  in  some  detail  under  the  general 
discussion  of  diagnosis. 

In  this  paper  it  is  only  intended  to  discuss  the  results  of  these 
investigations  and  to  consider  phases  of  the  subject  of  helminthology 
which  have  a  practical  medical  bearing.  No  attempt  has  been 
made  to  review  the  enormous  literature,  but  work  will  only  be  cited 
which  has  a  bearing  on  the  investigations  or  is  not  to  be  found  in  the 
usual  text-books.  The  investigations  were  conducted  upon  310 
children  between  two  and  twelve  years  of  age.  For  purposes  of 
convenience  and  accuracy  the  cases  have  been  divided  into  two 
groups.    The  first  group  comprises  30  cases,  the  second  280. 

The  first  group  of  thirty  examinations  were  made  entirely  on  the 
basis  of  suspicious  symptoms,  and  were  in  no  way  consecutive; 
hence  they  are  of  little  statistical  value.  This  portion  of  the  work 
extended  over  a  period  of  four  months,  and  the  children  examined 
suffered  from  obscure  nervous  or  gastrointestinal  disorders,  which 
were  not  explained  by  the  history  or  physical  examination.  This 
group  also  includes  4  cases  in  which  the  parasites  had  been  seen 
previous  to  admission. 

As  shown  in  Table  I,  twelve  of  the  children  in  this  group 
harbored  intestinal  worms,  and,  with  the  exception  of  one  case 
(VII),  the  relationship  of  the  symptoms  to  the  presence  of  the 
parasite  is  shown  by  the  influence  of  treatment.  In  the  case  men- 
tioned the  child  disappeared  from  observation  before  treatment 
could  be  instituted,  and  in  consideration  of  the  fact  that  the  parasite 
harbored  rarely  produces  symptoms,  this  case  must  be  considered 
doubtful.  Three  other  cases  (IV,  V,  and  XII)  were  lost  track  of 
after  treatment  was  begun,  but  the  nature  of  the  symptoms  and 
the  improvement  with  treatment  give  sufficient  indication  that  the 
intestinal  worms  were  the  causative  agency.  The  parasites  found 
in  the  12  positive  cases  were  as  follows:  Ascaris  lumbricoides  in 
2  cases,  Trichuris  trichiura  in  2  cases,  and  Oxyuris  vermicularis  in 
the  remaining  8  cases.  The  symptomatology  and  blood  examina- 
tions will  be  dealt  with  under  the  headings  of  the  different  parasites. 

The  second  group  comprises  280  examinations,  which  were  made 
as  nearly  consecutive  as  possible,  on  all  children  within  the  pre- 
scribed age  limits  from  families  whose  members  were  under  treat- 
ment at  the  clinics.  These  investigations  extended  over  a  period 
of  thirteen  months.    From  this  group  of  280  children,  80  (28.57 


SCHLOSS :  HELMINTHIASIS  IN  CHILDREN 


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per  cent.)  harbored  intestinal  worms.  Five  of  these  80  children 
were  infected  with  two  species  of  parasite,  which  gives  a  total  of  85 
infections.  Thirty-one  (11.07  per  cent.)  of  the  children  were 
infected  with  Trichuris  trichiura,  23  (8.21  per  cent.)  harbored 
Oxyuris  vermicularis,  20  (7.14  per  cent.)  were  infected  with  Hymeno- 
lepis  nana,  6  cases  (2.14  per  cent.)  harbored  Ascaris  lumbricoides, 
and  Tenia  saginata  was  found  in  5  cases  (1.78  per  cent.). 

In  the  double  infections,  Hymenolepis  nana  and  Trichuris 
trichiura  were  present  together  in  2  cases,  Hymenolepis  nana  and 
Oxyuris  vermicularis  in  1  case,  and  Ascaris  lumbricoides  and 
Oxyuris  vermicularis  were  associated  in  2  cases.  Out  of  the  total 
of  85  infections,  Trichuris  trichiura  occurred  in  36.47  per  cent., 
Oxyuris  vermicularis  in  27.05  per  cent.,  Hymenolepis  nana  in  23.52 
per  cent.,  Ascaris  lumbricoides  in  7.05  per  cent.,  and  Tenia 
saginata  in  5.88  per  cent. 

The  only  recent  statistical  study  of  the  intestinal  worms  of  children 
in  this  country  that  I  have  been  able  to  find  is  that  of  Stiles  and 
Garrison.1  These  investigators  examined  the  feces  of  123  children 
under  fifteen  years  of  age,  and  found  evidence  of  infection  with 
intestinal  worms  in  26  cases  (21.14  per  cent.).  Trichuris  trichiura 
was  present  in  16  cases  (13.01  per  cent.),  Oxyuris  vermicularis  in 
2  cases  (1.63  per  cent.),  Ascaris  lumbricoides  in  1  case  (0.81  per 
cent.),  and  Hymenolepis  nana  in  6  cases  (4.88  per  cent.).  There 
were  no  cases  of  infection  with  Tenia  saginata  in  children. 

The  important  features  of  my  cases  will  be  considered  under  the 
headings  of  the  different  parasites. 

Trichuris  trichiura  (Trichocephalus  dispar,  T.  hominis,  T. 
trichiura,  the  whipworm).  Table  II;  Cases  VII  and  IX,  Table  I. 
In  the  first  group  of  examinations  (Table  I)  there  were  2  instances 
of  infection  with  this  parasite;  in  the  second  group,  31.  In  2  cases 
of  the  second  group  this  parasite  was  found  in  association  with 
Hymenolepis  nana. 

Symptomatology.  None  of  the  cases  in  the  second  group  pre- 
sented symptoms  due  to  the  whipworm,  and  1  of  the  2  cases  in  the 
first  group  must  be  excluded,  since  the  relationship  of  the  symptoms 
to  the  presence  of  the  parasite  is  unproved.  There  seems  little  doubt 
that  the  symptoms  in  the  other  case  (IX,  Table  I)  were  due  to  the 
presence  of  the  parasite.  This  patient,  a  boy,  aged  seven  years,  had 
lost  weight  for  nearly  a  year,  and  during  this  time  he  had  become 
pale  and  listless.  Appetite,  sleep,  and  bowel  movements  were 
normal.  There  was  slight  puffiness  of  the  lower  eyelids,  and  the 
blood  showed  a  moderate  grade  of  secondary  anemia  with  the 
presence  of  nucleated  red  cells  (normoblasts).  The  number  of  red 
cells  was  3,100,000  per  cubic  millimeter,  and  the  hemoglobin  40 
per  cent.    The  urine  was  negative.    The  usual  tonics  (iron,  arsenic, 

»  Bull.  No.  28,  Hyg.  Lab.  U.  S.  Pub.  Health  and  Marine  Hosp.  Serv.,  1906. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


679 


and  cod-liver  oil)  had  been  administered  over  a  period  of  four 
months,  with  little  benefit.  Numerous  ova  of  the  whipworm  were 
discovered  in  the  feces,  and  the  patient  was  treated  on  the  basis  of 
this  finding.  Twice  a  week  for  three  weeks  thymol  (12  grains) 
was  given  in  divided  doses,  and  during  this  time  the  feces  were 
frequently  examined  to  determine  the  number  of  ova.  After  the 
first  two  treatments  the  number  of  ova  greatly  diminished,  and 
then  remained  stationary.  Irrigations  of  salt  water,  quassia,  and 
garlic  infusions  were  given  with  little  appreciable  effect.  Benzine 
irrigations  were  given  according  to  the  recommendation  of  Hem- 
meter,2  with  the  result  that  the  feces  became  free  from  ova.  No 
other  treatment  was  used,  and  no  change  was  made  in  the  mode  of 
life.  The  improvement  was  marked.  At  the  end  of  eight  weeks 
the  patient  had  gained  three  and  a  half  pounds  and  the  hemoglobin 
had  risen  to  65  per  cent.  Owing  to  the  distance  at  which  the 
patient  lived  it  was  impossible  to  examine  the  feces  to  determine 
the  number  of  parasites  expelled.  The  mother,  however,  noted  the 
parasites,  and  specimens  were  brought  for  verification. 

This  case  is  given  in  some  detail,  because  the  whipworm  is  in  most 
instances  a  harmless  parasite.  In  some  cases,  however,  when 
present  in  large  numbers,  this  parasite  may  give  rise  to  severe 
symptoms,  and  may  even  cause  death.  This  is  not  surprising, 
since  Askanazy3  has  shown  that  the  intestinal  canal  of  this  parasite 
contains  blood  pigment,  and  Guiart  and  Garin4  found  that  the 
stools  of  those  infected  reacted  positively  to  the  Weber  test  for  occult 
blood.  Becker5  has  collected  cases  from  the  literature  in  which  the 
whipworm  was  responsible  for  definite  symptoms.  The  symptoms 
were  frequently  intestinal:  diarrhoea,  often  with  bloody  stools, 
vomiting,  abdominal  pain,  etc.  In  other  cases  nervous  symptoms, 
such  as  dizziness  and  severe  headaches,  occurred.  Becker  reported 
a  case  of  secondary  anemia  which  closely  resembles  the  case  cited. 
Theodor6  reported  a  case  of  progressive  pernicious  anemia  in  a 
boy,  aged  eleven  years,  whose  stools  contained  numerous  ova  of  T. 
trichiura.  Somewhat  similar  cases  have  been  reported  by  Ostrovsky7 
and  by  Sandler.8 

Blood  Examinations?    The  published  reports  on  this  subject 

2  Diseases  of  the  Intestine,  1902,  p.  582. 
3Deut.  Archiv  f.  klin.  Med.,  1896,  lvii,  104. 

4  Semaine  me\i.,  xxix,  No.  35. 

5  Deut.  med.  Woch.,  June  26,  1902,  p.  648. 

6  Archiv  f.  Kinderheilk.,  1900,  xxviii. 

7  Abst.  New  York  Med.  Jour.,  1900,  lxxii,  826. 
s  Deut.  med.  Woch.,  1905,  xxxi,  95. 

9  The  differential  counts  were  made  from  blood  smears  stained  with  Wright's  stain, 
and  500  to  1000  cells  were  counted.  Most  of  the  hemoglobin  estimations  were  made  with 
the  Sahli  hemometer.  The  instrument  used  had  been  standardized  by  the  blood  of  normal 
children.  The  average  percentage  of  hemoglobin  in  children  between  two  and  six  years  was 
70  to  80  per  cent;  in  children  six  to  twelve  years  of  age,  75  to  85  per  cent.  A  few  of  the 
hemoglobin  estimations  were  made  with  the  Talquist  scale,  which  I  have  found  to  give 
readings  approximately  the  same  as  the  Sahli  instrument.  When  counts  of  the  blood  cells 
were  made,  the  Thoma-Zeiss  ap  aratus  was  used. 


680 


SCHLOSSI  HELMINTHIASIS  IN  CHILDREN 


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SCHLOSS!  HELMINTHIASIS  IN  CHILDREN 


indicate  that  the  whipworm  rarely  produces  an  increase  in  the  per- 
centage of  the  eosinophile  cells.  In  the  case  reported  by  Becker 
the  eosinophile  cells  were  2  per  cent.  French  and  Boycott10 
made  differential  blood  counts  on  26  patients  who  harbored  this 
parasite,  and  found  that  the  eosinophile  cells  were  not  increased. 
One  case  showed  5.5  per  cent,  of  eosinophile  cells,  but  even  though 
5  per  cent,  is  taken  as  an  arbitrary  standard,  this  single  observation 
is  of  little  importance.  Brown11  mentions  that  in  no  less  than  10  or 
12  cases  in  which  Trichocephalus  hominis  appeared  alone,  the  per- 
centage of  eosinophile  cells  rarely  fell  below  5.  No  cases  are 
cited,  nor  are  the  exact  percentages  of  the  eosinophile  cells  given. 
Naegeli12  has  found  eosinophilia  in  whipworm  infections.  Manson13 
says  that  in  some  few  cases  eosinophilia  was  found  in  persons 
infected  with  this  parasite,  but  that  this  does  not  appear  to  be  the 
rule.  I  have  made  differential  counts  in  18  cases  of  single  infection 
with  the  whipworm,  and  in  only  1  case  was  the  percentage  of 
eosinophile  cells  above  5  (XXVII,  Table  II).  In  this  case  the 
eosinophile  cells  were  6.4  per  cent.  Two  other  children  from  the 
same  family  harbored  the  threadworm,  and  it  is  quite  possible  that 
the  patient  in  question  was  infected  with  threadworms,  which  were 
not  detected  in  the  routine  examination. 

Treatment.  It  is  fortunate  that  this  parasite  so  rarely  causes 
symptoms,  for  the  treatment  is  notoriously  unsatisfactory.  Stiles14 
cites  an  instance  in  which  300  parasites  were  expelled  by  thymol.  In 
experimental  infections  in  dogs  Stiles  and  Pfender  found  thymol 
of  little  value.  In  the  single  case  in  which  treatment  was  given  by 
me,  the  number  of  parasites  seemed  to  decrease  under  treatment 
with  thymol,  judging  by  the  number  of  ova  found  in  the  stools,  and 
the  ova  finally  disappeared  with  the  use  of  benzine  irrigations. 

Oxyuris  vermicularis  (the  threadworm,  pinworm,  or  seatworm). 
Table  III;  Cases  III,  IV,  V,  VI,  VIII,  X,  XI,  and  XII,  Table  I. 
In  the  consecutive  examinations  there  were  23  cases  of  infection 
with  this  parasite,  but  I  am  of  the  opinion  that  more  children 
harbor  this  worm  than  is  indicated  by  these  figures.  It  is  well 
known  that  the  ova  of  this  parasite  are  not  frequently  found  in  the 
feces,  but  that  the  female  worms  are  more  often  present.  It  is  pos- 
sible that  when  only  a  comparatively  small  number  of  worms  are 
harbored  they  may  be  passed  intermittently,  and  in  consequence 
not  be  found  in  a  single  examination.  Moreover,  the  small  speci- 
mens of  feces  obtainable  for  these  examinations  may  not  have  con- 
tained the  worms,  even  though  they  were  being  passed  at  the  time. 
Although  in  most  instances  a  calomel  purge  was  given  before 

10  Jour.  Hyg.,  1905,  v,  274. 

11  Bost.  Med.  and  Surg.  Jour.,  cxlviii,  583. 

12  Blutkrankheiten  u.  Blutdiagnostick,  von  Veit,  Leipzig,  1908. 

13  System  of  Medicine,  Albutt  andRolleston,  1907,  vol.  ii,  part  ii,  p.  908. 

14  Modern  Medicine,  Osier  and  McCrae,  1907,  i,  604. 


SCHLOSSI  HELMINTHIASIS  IN  CHILDREN 


683 


obtaining  the  specimens  of  feces,  three  of  the  charted  cases  show  how 
easily  these  worms  may  be  overlooked.  In  Case  IV,  Table  III, 
the  presence  of  this  worm  was  not  suspected,  but  two  pregnant 
female  oxyurides  were  found  in  the  feces  after  treatment  for  H. 
nana.  Similarly,  in  Cases  V  and  XVI,  threadworms  were  dis- 
covered in  the  feces  after  the  administration  of  santonin  in  the 
treatment  for  ascaris.  The  autopsy  records  of  Still15  are  interesting, 
as  showing  the  frequency  of  this  worm.  Out  of  200  consecutive 
autopsies  performed  at  the  Great  Ormond  Street  Hospital,  in  Lon- 
don, Still  found  the  threadworm  in  32  of  100  children  between  two 
and  ten  years  of  age. 

Symptomatology.  In  6  cases  from  the  second  group  of  exami- 
nations the  threadworm  was  present  without  giving  rise  to  svmp- 
toms  (I,  IV,  V,  VII,  XV,  and  XVI,  Table  III).  In  one  of  these  cases 
(XV)  the  child  had  previously  suffered  from  symptoms,  but  none 
were  present  at  the  time  of  examination.  The  irritative  symptoms 
produced  by  the  nocturnal  wanderings  of  these  worms  usually  leads 
to  their  detection,  but  when  local  symptoms  (rectal  irritation, 
genital  pruritus,  etc.)  are  absent,  the  infection  may  not  be  suspected. 
In  4  cases  from  the  first  group  of  examinations,  and  in  5  of  17 
children  from  the  second  group,  who  suffered  from  symptoms,  the 
mother  was  not  aware  of  the  infection. 

The  most  frequent  symptoms  referable  to  the  threadworm  are  those 
of  irritative  nature  due  to  the  migration  of  the  pregnant  female 
worms.  In  this  class  is  the  genital  pruritis  and  the  rectal  irritation. 
The  vulvitis  and  masturbation  in  Case  V,  Table  I,  were  probably 
of  this  origin,  and  both  of  these  symptoms  disappeared  after  appro- 
priate treatment.  Loss  of  weight,  anemia,  and  headache  are  not 
infrequent  symptoms,  and  may  form  the  complaint  for  which  the 
child  is  brought  to  the  physician.  This  fact  has  been  pointed  out 
by  Still.16  The  reflex  nervous  disturbances  produced  by  this  para- 
site are  of  importance.  Restlessness  at  night,  grinding  of  the  teeth, 
night  cries,  and  general  irritability  are  particularly  frequent.  Cases 
are  reported  in  which  the  threadworm  may  be  responsible  for  con- 
vulsions or  choreiform  movements.  Holt17  cites  a  case  in  which 
threadworms  were  the  probable  cause  of  chorea.  Gastro-intestinal 
symptoms  are  rather  common.  Still18  has  called  particular  atten- 
tion to  pain  in  the  lower  part  of  the  abdomen  and  right  iliac 
fossa  as  a  symptom  in  Oxyuris  infections.  Sometimes  the  pains 
are  referred  to  the  umbilical  region.  Ashhurst19  has  recently 
reported  a  case  in  which,  on  operation  for  appendicitis,  the  appendix 
was  found  to  contain  numerous  oxyurides.    Culhane20  has  reported 

15  Brit.  Med.  Jour.,  1899,  i,  898. 

16  Common  Disorders  of  Childhood,  1909. 

17  Diseases  of  Infancy  and  Childhood,  1909. 
13  Common  Disorders  of  Childhood,  1909. 

19  Amur.  Jour.  Med.  Sci.,  October,  1909,  p.  583. 

20  Jour.  Amer.  Med.  Assoc.,  1910,  liv,  48. 


684 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


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686 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


a  similar  case,  and  considers  that  the  oxyurides  were  the  cause  of 
the  appendicitis.  Still21  noted  thickening  and  swelling  of  the 
appendix  in  some  of  his  autopsies. 

Pains  in  the  lower  part  of  the  abdomen  or  right  iliac  fossa 
were  present  in  4  of  my  cases.  The  pains  caused  considerable 
annoyance,  and  in  1  case  were  of  moderate  severity.  In  these  cases 
the  temperature  was  normal  and  tenderness  on  palpation  or  muscle 
spasm  were  never  elicited.  The  appetite  was  poor  in  11  cases, 
capricious  in  5,  excessive  in  2,  and  normal  in  7  cases.  In  1  case 
flatulency  and  nausea  were  complained  of;  in  another,  nausea  alone. 
Diarrhoea,  with  blood  and  mucus  in  the  stools,  may  be  produced  by 
this  parasite.  Diarrhoea  was  not  a  symptom  in  any  of  my  cases, 
but  constipation  was  frequent. 

Blood  Examinations.  Differential  blood  counts  were  made  on 
22  patients  who  suffered  from  symptoms  due  to  Oxyuris  vermicu- 
laris,  and  in  17  the  eosinophile  cells  were  above  5  per  cent.  The 
percentage  of  the  esoinophile  cells  varied  greatly,  and  was  between 
6  and  10  per  cent,  in  12  cases,  between  10  and  20  per  cent,  in  4 
cases,  and  above  20  per  cent,  in  1  case.  The  eosinophile  cells  were 
not  increased  in  5  of  the  cases  showing  symptoms.  Three  of  these 
cases  (III,  VI,  and  IX,  Table  III),  from  the  second  group  of  exami- 
nations, gave  a  history  of  infection  with  the  threadworm  for  one, 
three,  and  two  years,  respectively,  and  the  hemoglobin  percentage 
in  all  3  was  low.  Case  IX  showed  a  moderate  grade  of  secondary 
anemia,  with  a  red  cell  count  of  3,600,000,  a  leukocyte  count  of 
5000,  and  a  hemoglobin  percentage  of  40.  In  Case  III  the 
hemoglobin  was  65  per  cent.,  in  Case  VI  it  was  55  per  cent.  In  the 
two  cases  from  the  first  group  of  examinations  (V  and  VI,  Table  I) 
it  was  impossible  to  determine  the  duration  of  infection.  In  both 
cases  the  hemoglobin  percentage  was  low.  One  patient,  however 
(XXIII,  Table  III),  gave  a  history  of  an  infection  of  three  years' 
duration,  and  the  eosinophile  cells  were  6  per  cent.  Differential 
blood  counts  were  made  on  3  patients  who  did  not  suffer  from 
symptoms,  none  of  which  showed  an  increased  percentage  of  eosino- 
phile cells. 

Case  VIII,  Table  I,  is  of  particular  interest,  since  this  child  was 
seen  at  the  height  of  the  infection,  and  the  percentage  of  the  eosino- 
phile cells  was  followed  during  treatment.  This  patient  suffered 
from  rather  pronounced  symptoms,  and  at  the  time  of  admission 
the  eosinophile  cells  were  33  per  cent.,  the  red  blood  cells  4,100,000 
per  cubic  millimeter,  the  leukocytes  16,000  per  cubic  millimeter, 
and  the  hemoglobin  70  per  cent.  After  treatment  for  five  days  the 
symptoms  were  much  less  severe,  and  the  eosinophile  cells  were  13 
per  cent.  Two  weeks  later  the  patient  was  free  from  symptoms, 
and  at  this  time  the  eosinophile  cells  had  fallen  to  3  per  cent. 


2!  Brit.  Med,  Jour.,  1899,  i,  898. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


687 


In  Boycott's22  cases  the  eosinophile  cells  were  above  5  per  cent, 
in  8  out  of  18  cases  of  threadworm  infection  in  children.  In  the 
remaining  10  cases  the  eosinophile  cells  were  not  increased.  No 
mention  is  made  of  the  presence  or  absence  of  symptoms,  but  this 
investigator  suggests  that  the  presence  of  eosinophilia  bears  relation 
to  the  duration  of  infection. 

Treatment.  There  are  several  observations,  not  generally  recog- 
nized, which  have  direct  bearing  on  the  treatment  for  this  parasite. 
An  experiment  of  Grazzi23  shows  that  the  worms  may  arrive  at 
maturity  in  the  intestines  during  the  last  four  or  five  weeks  following 
a  single  infection.  Since  it  is  probable  that  fresh  parasites  con- 
stantly develop  through  auto-infection,  the  treatment  should  be- 
continued  for  six  weeks. 

In  the  autopsies  of  Still24  the  worms  were  found  in  the  appendix 
in  25  of  the  38  cases  which  harbored  Oxyuris  vermicularis;  in  6 
cases  the  appendix  seemed  to  be  the  only  habitat. 

The  normal  habitat  of  this  worm  is  the  cecum  or  appendix,  and 
not  the  rectum  and  colon,  as  often  stated.  When  the  females 
become  impregnated  they  migrate  to  the  lower  portions  of  the  large 
intestine  to  discharge  their  ova.  They  often  wander  through  the 
rectum  and  may  pass  out  with  the  feces.  Thus,  the  treatment  should 
be  given  with  two  aims:  first,  to  remove  the  worms  which  have 
migrated  to  the  large  intestine;  and  next,  to  expel  those  in  the 
cecum  or  appendix.  For  the  former  purpose  the  usual  irrigations 
of  salt  water,  quassia,  garlic,  etc.,  are  effective.  As  fluid  injected 
per  rectum  may  not  always  reach  the  cecum,  internal  treatment  is 
of  importance.  Santonin  is  probably  the  most  useful  drug  for  this 
purpose,  and  is  best  given  in  doses  of  1  to  3  grains,  with  the  same 
amount  of  calomel,  for  three  successive  evenings.  On  the  first  and 
third  mornings  of  treatment  a  cathartic  should  be  given.  This 
treatment  may  be  repeated  two  or  three  times  during  the  first  three 
weeks. 

During  the  first  two  or  three  weeks  the  irrigations  should  be  given 
each  evening,  and  from  6  to  20  ounces — depending  on  the  age  of 
the  patient — can  be  given  in  each  injection.  Later,  the  irrigations 
may  be  given  every  alternate  evening,  and  finally  twice  a  week. 
Every  effort  should  be  made  to  prevent  auto-infection,  as  this  is  a 
potent  factor  in  keeping  up  the  disease.  At  night  a  mild  mercurial 
ointment  (10  to  20  per  cent.)  may  be  applied  around  the  rectum. 
The  child  should  be  prevented  from  scratching  and  from  putting 
his  fingers  into  his  mouth. 

A  review  of  the  tabulated  cases  shows  how  unsatisfactory  the  usual 
treatment  may  be.  The  mothers  usually  give  the  irrigations  only 
during  the  period  of  active  symptoms,  or  while  worms  are  passed; 

22  Brit.  Med.  Jour.,  1903,  ii,  1267. 

2a  Quoted  by  Manson,  System  of  Medicine,  Allbutt  and  Rolleston,  1907,  vol.  ii,  part  ii,  p.  891. 
24  Brit.  Med.  Jour.,  1899,  i,  898. 


688 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


often  within  two  to  four  months  the  patients  again  show  signs  of 
severe  infection.  Although  this  parasite  rarely,  if  ever,  produces 
dangerous  symptoms,  yet  the  continual  irritation  which  they  set  up 
may  undermine  the  general  health;  this  serves  as  a  sufficient  indi- 
cation for  thorough  treatment. 

Hymenolepis  nana  (Tenia  murina,  Tenia  nana,  the  dwarf  tape- 
worm). Table  IV.25  There  were  20  cases,  of  infection  with  this 
parasite  out  of  the  280  consecutive  examinations.  Nineteen  of  the 
patients  were  born  in  New  York  City;  1  patient  was  born  in  Sicily, 
and  came  to  this  country  at  the  age  of  four  years.  This  may  have 
been  an  imported  case,  as  the  dwarf  tapeworm  is  a  comparatively 
common  parasite  in  certain  parts  of  Sicily. 

Previous  to  the  paper  of  Stiles,26  in  1903,  the  dwarf  tapeworm  was 
not  considered  a  common  American  parasite,  but  since  this  time  a 
number  of  cases  have  been  recognized  in  different  sections  of  the 
country.  In  my  investigations  this  parasite  was  the  third  in  fre- 
quency, and  there  is  every  indication  that  it  is  a  comparatively 
common,  though  perhaps  unrecognized,  parasite  of  children. 

Seventy-nine,  or  74.52  per  cent.,  of  the  cases  collected  by  Ransom27 
in  1904  were  in  children,  and  this  parasite  has  been  generally 
recognized  as  occurring  most  frequently  in  individuals  under  sixteen 
years  of  age. 

No  attempt  will  be  made  to  give  a  description  of  the  parasite, 
as  this  has  been  done  in  another  paper.  The  dwarf  tapeworm 
possesses  certain  points  of  similarity  to  the  larger  tapeworms,  but 
differs  in  its  minute  size  and  the  great  number  of  the  parasites  usually 
present.  The  average  length  of  the  parasite  ranges  below  20  mm. 
(0.8  inch),  and  the  worm  contains  from  110  to  200  segments. 
The  number  of  parasites  present  in  a  single  patient  varies  from 
a  few  to  thousands.  After  treatment,  50  worms  were  recovered 
from  the  feces  of  one  of  my  cases,  and  60  from  another;  all  of 
the  other  patients  harbored  more  than  100  parasites,  and  one 
patient  harbored  many  more  than  2000.  The  number  of  parasites 
could  be  estimated  in  only  11  cases. 

Symptoms.  This  parasite  is  of  unusual  medical  interest,  as  a 
number  of  those  infected  suffer  from  symptoms  referable  to  its 
presence.  In  Ransom's28  analysis  of  the  cases  reported  up  to  1904 
the  most  frequent  symptoms  were  of  the  nature  of  nervous  or  gastro- 
intestinal disorders.  The  nervous  symptoms  ranged  from  mild 
disturbances,  such  as  nervousness,  irritability,  and  restlessness  at 


25  Fourteen  of  these  cases  (I,  II,  III,  IV,  VI,  VII,  VIII,  XIII,  XIV,  XVI,  XVII,  XVIII, 
XIX,  XX)  have  been  published  in  the  February  number  of  the  Archives  of  Pediatrics.  In 
this  paper  the  parasite  and  ova  are  described  and  the  recent  literature  reviewed.  Three 
other  cases  (V,  IX,  and  XII)  will  be  reported  in  the  Jour.  Amer.  Med.  Assoc.,  April,  1910. 

26  New  York  Med.  Jour.,  1903,  lxxviii,  877. 

"  Bull.  18,  Hyg.  Lab.  U.  S.  Pub.  Health  and  Mar.  Hosp.  Serv.,  1904. 
28  Ibid. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


689 


night,  to  severer  manifestations,  such  as  choreiform  movements 
and  definite  convulsive  seizures. 

Among  the  symptoms  referable  to  the  gastro-intestinal  tract,  pain 
or  paresthesia  are  common.  The  pain  is  colicky,  is  usually 
referred  to  the  epigastrium,  and  occurs  in  paroxysms.  These 
attacks  of  pain  may  be  infrequent,  but  they  often  occur  several 
times  a  day.  Ransom29  refers  to  one  case  in  which  there  was  epigas- 
tric tenderness  in  association  with  the  pain.  Abdominal  paresthesia, 
in  the  nature  of  a  sudden  sinking  sensation,  or  a  sudden  feeling  of 
"goneness,"  is  not  uncommon  in  older  children.  Diarrhoea  some- 
times occurs.  Deaderick30  has  reported  6  cases  of  dwarf  tapeworm 
infection,  all  of  which  presented  symptoms  which  were  attributed 
to  the  presence  of  the  parasite.  According  to  him  the  most  com- 
mon symptoms  were,  in  the  order  of  frequency,  nausea,  vomiting, 
oedema,  headache,  abdominal  pain,  diarrhoea,  dyspnoea,  and  con- 
vulsions. 

In  8  of  my  cases  there  were  no  symptoms  attributable  to  the 
dwarf  tapeworm  infection;  in  12  cases  there  were  well-marked 
symptoms,  which  disappeared  or  were  greatly  ameliorated  after 
appropriate  treatment.  The  symptoms  were  mild  in  5  cases, 
moderate  in  4,  and  rather  severe  in  3  cases. 

The  most  common  nervous  symptoms  were  restlessness  at  night, 
night  cries,  grinding  the  teeth  during  the  night,  and  general  irrita- 
bility. Numbness  and  tingling  in  one  hand  was  a  symptom  in  1 
case.  One  patient  (IX)  had  three  general  convulsions,  and  the 
disappearance  of  all  symptoms  since  the  expulsion  of  H.  nana 
indicates  that  the  intestinal  parasites  were  the  exciting  cause. 
Itching  of  the  nose  and  genital  region  were  not  infrequent. 

The  most  common  gastro-intestinal  symptom  was  epigastric 
pain.  This  symptom  was  present  in  7  cases.  The  pain  was  colicky, 
and  was  most  often  mild  and  transient,  but  in  2  cases  it  was  quite 
severe.  There  were  no  abdominal  signs  in  these  cases;  tenderness 
on  palpation,  muscle  spasm,  or  rigidity  were  never  present.  Diar- 
rhoea was  present  in  1  case,  attacks  of  nausea  and  vomiting  in  1 
case,  and  nausea  unaccompanied  by  vomiting  in  1  case.  The 
appetite  was  increased  in  3  cases,  capricious  in  1,  decreased  in  5, 
and  apparently  normal  in  the  remaining  4  cases.  One  patient 
complained  of  a  sudden  sinking  sensation,  referable  to  the  abdominal 
organs. 

Pain  in  the  lower  limbs  was  complained  of  in  2  cases,  and  in  1  it 
was  quite  severe.  (Edema  of  the  lower  eyelids  was  a  sign  in  2 
cases.  Loss  of  weight  was  a  rather  prominent  feature  in  3  cases; 
in  the  other  cases,  however,  even  in  those  with  severe  symptoms, 
emaciation  was  not  evident. 

2f  Bull.  18,  Hyg.,  Lab.  U.  S.  Pub.  Health  and  Mar.  Hosp.  Serv.,  1904. 
30Internat.  Clinics,  1909,  iv;  Jour.  Amer.  Med.  Assoc.,  1906,  xlviii,  2087. 


690 


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Blood  Examinations.  The  blood  examinations  present  points  of 
especial  interest.  With  a  single  exception,  the  percentage  of  eosino- 
phil cells  was  increased  in  the  patients  who  suffered  from  symp- 
toms. The  exceptional  case  was  one  of  rather  long  standing  infec- 
tion with  pronounced  secondary  anemia.  The  eosinophile  cells 
were  between  6  and  10  per  cent,  in  7  cases,  between  10  and  20  per 
cent,  in  3  cases,  and  above  20  per  cent,  in  1  case.  The  eosinophile 
cells  were  above  5  per  cent,  in  only  1  of  the  cases  without  symptoms, 
and  in  this  case  the  eosinophile  cells  were  5.2  per  cent.  The  hemo- 
globin was  determined  in  all  cases,  and  in  a  number  the  percentage 
was  below  normal.  The  red  blood  cells  were  counted  in  4  cases 
(V,  XIV,  XVI,  and  XVIII),  and  in  all  a  secondary  anemia  was 
present.  The  degree  of  anemia  may  be  characterized  as  mild  in 
1  case,  moderate  in  2,  and  rather  severe  in  1  case.  In  1  case  micro- 
cytes  and  normoblasts  were  present  in  the  blood.  In  a  number  of 
the  cases  with  eosinohpilia  the  number  of  leukocytes  seemed  to  be 
increased. 

A  case  of  infection  with  Hymenolepis  nana  is  cited  by  Bucklers,31 
in  which  the  eosinophile  cells  were  7  per  cent.  No  mention  is 
made  in  this  case  of  the  presence  or  absence  of  symptoms. 
Deaderick32  has  reported  6  cases  of  dwarf  tapeworm  infection 
which  showed  an  eosinophilia  of  11.5,  15,  9,  26,  8.2,  and  7.8  per 
cent.,  respectively.  All  of  these  patients  had  symptoms  appar- 
ently due  to  the  parasites. 

Treatment.  Oleoresin  of  male  fern  is  the  remedy  generally 
recommended,  and  is  quite  effective.  Before  the  administration 
of  the  anthelmintic  it  is  desirable  to  have  the  intestinal  canal  as 
empty  as  possible.  To  accomplish  this  the  diet  should  be  restricted 
to  easily  digested  food  for  several  days  and  a  cathartic  given  each 
day.  On  the  evening  before  the  specific  treatment  a  cathartic 
should  be  given;  the  oleoresin  of  male  fern  should  be  administered 
the  following  morning.  It  is  of  importance  that  the  remedy  be 
fresh,  and  it  is  best  administered  on  an  empty  stomach.  The  dose 
will  naturally  vary  with  the  age  of  the  patient;  from  \  to  1  dram 
is  sufficient,  and  has,  in  my  experience,  been  entirely  harmless.  It 
is  best  to  give  the  male  fern  in  three  to  five  doses,  administered  at 
half-hour  intervals.  One-half  hour  after  the  last  dose  of  male 
fern  a  brisk  saline  purge  should  be  given. 

A  single  treatment  is  not  always  sufficient,  but  its  effectiveness  can 
be  determined  by  a  later  examination  of  the  feces  for  ova.  When 
worms  are  left  in  the  intestinal  canal,  or  develop  after  treatment, 
the  ova  usually  reappear  after  an  interval  of  about  fifteen  days. 

Ascaris  lumbricoides  (the  common  roundworm,  the  eelworm). 
Table  V;  Cases  I  and  II,  Table  I.    In  the  first  group  of  examina- 

31  Munch,  med.  Woch.,  1894,  xli,  22  and  47. 

32  Jour.  Amer.  Med.  Assoc.,  1906,  xlvii,  2087;  Internat.  Clinics,  1909,  iv. 


SCHLOSS!  HELMINTHIASIS  IN  CHILDREN 


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SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


tions  (Table  I)  there  were  2  cases  of  infection  with  this  parasite; 
there  were  6  cases  (2.14  per  cent.)  in  the  280  consecutive  examina- 
tions. 

The  2  cases  from  the  first  group  are  of  sufficient  interest  to  give 
in  some  detail.  In  the  first  case,  the  onset  of  the  illness  was  sudden, 
with  vomiting  and  loss  of  appetite.  The  child  was  very  restless  at 
night,  and  would  frequently  awake  and  cry  out  as  if  in  pain.  For 
ten  days  these  symptoms  continued;  the  evening  temperature 
ranged  from  101°  to  102°  F.,  and  the  respirations  and  pulse  were 
proportionately  increased.  The  patient  was  thoroughly  examined, 
but  nothing  could  be  found  to  account  for  the  symptoms.  On  the 
tenth  day  of  the  illness  a  blood  count  showed  the  presence  of  an 
eosinophilia  (12.1  per  cent.).  This  led  to  an  examination  of  the 
stools,  and  the  ova  of  ascaris  were  found  in  great  numbers.  The 
expulsion  of  a  lumbricoid  worm  by  santonin  was  followed  by  disap- 
pearance of  all  symptoms.  An  almost  identical  case  is  cited  by 
Still.33 

The  symptoms  in  the  other  case  (Table  II),  were  less  acute.  For 
three  months  the  patient  had  been  irritable,  pale,  and  had  lost 
weight.  At  the  time  of  admission  he  had  an  attack  of  jaundice; 
the  skin,  sclerotics,  and  mucous  membranes  were  distinctly  yellow. 
The  stools  were  colorless,  and  the  urine  contained  bile  pigments. 
At  this  time  the  eosinophile  cells  were  12.6  per  cent.,  and  the  ova  of 
A.  lumbricoides  were  found  in  the  feces.  After  treatment,  two 
ascarides  were  expelled.  The  jaundice  lasted  for  ten  days;  after 
its  disappearance  the  other  symptoms  improved,  and  the  child  began 
to  gain  in  weight.  This  patient  had  passed  a  roundworm  one 
month  previous  to  the  onset  of  the  recorded  illness. 

Two  of  the  6  cases  from  the  consecutive  examinations  suffered 
from  no  symptoms  referable  to  helminthiasis;  3  of  the  remaining 
4  cases  suffered  from  mild  symptoms;  in  one  case  the  symptoms 
were  rather  severe.  The  more  pronounced  symptoms  in  these  cases 
were  the  ones  commonly  due  to  the  presence  of  this  worm :  loss  of 
color  and  weight,  poor  appetite,  restlessness  at  night,  and  night 
cries.  One  patient  (II)  suffered  from  attacks  of  nausea  and  vom- 
iting, which  have  not  recurred  since  the  expulsion  of  one  lumbricoid 
worm. 

The  past  history  of  Case  III  was  rather  interesting.  Two  years 
before  admission  the  child  had  an  acute  illness,  accompanied  by 
fever  and  jaundice.  According  to  the  mother's  story,  recovery 
ensued  immediately  after  the  passage  of  one  lumbricoid  worm. 

Blood  Examinations.  In  the  2  cases  without  symptoms  the 
eosinophile  cells  were  not  increased.  In  all  of  the  cases  with  symp- 
toms, including  the  2  cases  from  the  first  group  of  examinations, 
there  was  a  moderate  degree  of  eosinophilia.  The  percentages  of 
eosinophile  cells  varied  from  6.2  to  12.6. 

33  Common  Disorders  of  Childhood,  1909. 


SCHLOSSI  HELMINTHIASIS  IN  CHILDREN 


695 


Treatment,  with  santonin  is  effective,  the  details  of  which  are 
given  in  all  of  the  text-books.  Experiments  have  shown  that  it 
takes  about  one  month  for  the  development  of  this  worm  from  the 
ovum  to  the  sexually  mature  parasite.  Therefore,  in  order  to  be 
sure  of  the  thoroughness  of  the  treatment,  the  feces  should  be 
examined  for  ova  after  one  month. 

Tenia  saginata  (T.  mediocanellata,  the  fat,  or  beef  tapeworm). 
Table  VI.  This  parasite  was  found  in  5  cases  (1.74  per  cent.),  and 
in  3  cases  the  segments  had  been  seen  by  the  mother,  who  was 
consequently  aware  of  the  infection.  In  2  cases  (II  and  III)  the 
diagnosis  was  made  by  finding  the  ova  in  the  feces,  and  later  con- 
firmed by  the  discovery  of  the  segments. 

Symptomatology.  Two  of  the  5  patients  suffered  from  no  symp- 
toms referable  to  the  tapeworm.  Two  of  the  remaining  3  patients 
suffered  from  nervousness;  1  child  had  become  quite  irritable,  and 
1  was  very  restless  during  sleep.  The  appetite  was  at  times 
excessive  in  1  case;  in  2  cases  it  was  meagre.  One  patient 
suffered  from  frequent  attacks  of  abdominal  colic,  and  the  pain 
was  referred  to  the  epigastrium.  None  of  the  patients  showed 
signs  of  emaciation. 

Blood  Examinations.  The  blood  was  not  examined  in  the  2  cases 
without  symptoms.  In  the  3  patients  who  suffered  from  symptoms 
the  percentage  of  the  eosinophile  cells  was  increased,  and  ranged 
from  7.1  per  cent,  to  13.2  per  cent. 

Treatment.  The  treatment  followed  in  these  cases  was  that 
given  under  Hymenolepis  nana. 

General  Discussion.  Symptomatology  and  Pathology.  The 
obscurity  of  the  symptoms  of  helminthiasis  and  the  irregularity 
with  which  they  occur  has  led  to  uncertainty  and  confusion.  It  is 
well  known  that  in  many  instances  intestinal  worms  produce  no 
appreciable  effect,  while  in  other  cases  they  may  be  responsible 
for  definite  symptoms  which  are  always  deleterious  and  sometimes 
severe. 

The  occurrence  of  symptoms  in  infection  with  the  common 
intestinal  worms  seems  to  be,  to  some  extent,  dependent  on  the 
number  of  the  parasites  present.  This  factor,  however,  can  be  of 
little  importance  with  parasites,  of  which,  as  a  rule,  only  a  single  worm 
or  a  small  number  of  worms  are  harbored.  The  cases  collected 
by  Becker,34  in  which  the  whipworm  was  responsible  for  severe 
symptoms,  were  all  infected  with  large  numbers  of  the  parasite. 
In  my  cases  it  was  in  instances  in  which  many  threadworms 
were  being  passed  that  the  symptoms  were  most  marked.  As  a 
rule,  the  cases  of  dwarf  tapeworm  infection  which  harbored  the 
largest  number  of  worms  suffered  the  most  noticeable  effects.  On 
the  other  hand,  one  finds  numerous  references  in  the  literature  which 


84  Deut.  med.  Woch,  June  2G,  1902,  648. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


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SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


697 


show  that  large  numbers  of  parasites  may  be  harbored  with  no 
apparent  discomfort  to  the  host.  Dehio35  believes  that  "Bothrio- 
cephalus  anemia"  is  only  produced  after  the  death  or  disease  of  the 
parasite,  but  even  if  this  is  true,  it  seems  scarcely  possible  that  this 
factor  comes  into  play  with  the  common  helminth. 

The  age  of  the  patient  is  of  great  importance,  for  it  is  well  known 
that  reflex  nervous  disturbances  are  more  likely  to  occur  in  children 
than  in  adults.  The  species  of  parasite  is  of  some  importance,  but 
in  infections  with  all  of  the  parasites  considered  in  this  paper  symp- 
toms are  inconstant.  There  is  no  adequate  explanation  for  this 
irregularity  in  the  occurrence  of  symptoms,  but  it  may  be  due  to  a 
definite  predisposition  on  the  part  of  some  individuals,  or  the  worms 
may  excrete  toxic  substances  only  under  certain  conditions,  of  the 
nature  of  which  we  are  ignorant.  It  is  not  improbable  that  both 
factors  are  of  importance. 

As  to  the  ultimate  cause  of  the  symptoms  of  helminthiasis  there 
is  little  positive  knowledge  and  much  speculation.  There  have 
been  experiments  which  indicate  that  some  parasites  at  least  excrete 
toxic  substances  which  may  have  an  influence  on  the  host,  and 
clinical  experience  often  lends  support  to  this  view.  A  case  has 
recently  been  reported  by  Artaega36  in  which  ascarides  were  the 
probable  cause  of  profound  hemolysis.  On  the  other  hand,  there 
are  symptoms  the  nature  of  which  suggests  an  irritative  action,  such 
as  diarrhoea  and  the  local  irritation  produced  by  migrating  oxyurides. 
Many  of  the  nervous  disturbances  are  probably  reflex,  due  to  the 
irritation  set  up  by  the  worms. 

It  has  been  mentioned  that  the  intestinal  canal  of  the  whipworm 
was  found  to  contain  blood  pigment,37  and  that  the  feces  of  those 
infected  with  this  parasite  reacted  to  an  occult  blood  test.38  Autop- 
sies have  shown  that  the  head  of  the  dwarf  tapeworm  burroughs 
into  the  intestinal  mucosa,  and  that  considerable  inflammation  may 
be  thus  produced.  Without  undue  speculation,  it  can  be  safely 
said  that  the  present  state  of  our  knowledge  indicates  that  the 
influence  of  the  common  intestinal  worms  is  due  to  direct  irritation, 
to  the  abstraction  of  blood,  or  to  toxic  substances  excreted  by  the 
parasite.39 

35  Quoted  by  Emerson,  Clinical  Diagnosis,  1906,  p.  389. 

36  Abst.  Jour.  Amer.  Med.  Assoc.,  May  8,  1909. 
37Deut.  Archiv  f.  klin.  Med.,  1896,  lvii,  104. 

38  Semaine  mdd.,  xxix,  p.  35. 

39  No  mention  is  made  of  the  well-known  mechanical  effects  due  to  the  migration  of  Ascar- 
ides. The  various  means  by  which  parasitic  worms  may  produce  injury  is  summarized  by 
Stiles  as  follows:  (1)  Nourishment  is  taken  which  should  go  to  the  host;  (2)  blood  is  taken 
by  the  parasites  as  food;  (3)  mechanical  pressure  irritates  or  causes  atrophy  of  organs 
or  parts  of  organs;  (4)  natural  channels  may  be  obstructed;  (5)  the  wandering  of  the 
parasites  may  cause  irritation;  (6)  substances  may  be  excreted  which  may  have  a  toxic 
influence,  and  which  may  change  the  natural  condition  of  the  body  fluids  (blood);  (7)  injury 
to  the  intestinal  mucosa  or  to  the  skin  may  form  points  of  entry  for  bacterial  or  protozoan 
infections  (Osier  and  McCrae,  Modern  Medicine,  vol.  i,  1907). 


698 


SCHLOSSI  HELMINTHIASIS  IN  CHILDREN 


The  most  important  symptoms  of  helminthiasis  may  be  tabulated 
as  follows: 

I.  Gastro-intestinal  symptoms. 

(A)  Nausea. 

(B)  Vomiting. 

(C)  Diarrhoea. 

(D)  Abdominal  pain. 

(E)  Jaundice.    Commonest  in  ascaris  infections.  May 

be  due  to  duodenitis  or  to  mechanical  obstruction 
of  a  bile  duct  by  a  parasite.  May  occur  in  tapeworm 
infections. 

(F)  Abdominal  paresthesia.40 

Sinking  sensations,  feeling  of  emptiness,  sensation 
of  "  goneness,"  .etc.  Commonest  in  tapeworm 
infections. 

(G)  Disturbances  of  appetite. 

1.  Increased  appetite. 

2.  Decreased  appetite. 

3.  Capricious  appetite. 

4.  Perverted  appetite. 

(H)  Intestinal  obstruction.  (Ascarides.) 

II.  Symptoms  of  nervous  organs.    (May  be  reflex  or  tonic?) 
(.4)  Disturbances  of  sleep. 

1.  Restlessness. 

2.  Grinding  of  teeth. 

3.  Night  cries. 

(B)  Irritability,  nervousness. 

(C)  Nasal  pruritus.41 

(D)  Dyspnoea. 

(E)  Dizziness  and  vertigo. 

(F)  Choreiform  movements. 

(G)  Convulsions. 

(H)  Paralysis.  (Functional.) 

III.  Symptoms  referable  to  organs  of  special  sense. 

(A)  Perversions  of — 

1.  Sight. 

2.  Hearing. 

3.  Taste. 

4.  Smell. 

(B)  Pupillary  changes. 

40 This  is  really  a  nervous  symptom,  but  since  the  sensations  are  referred  to  the  abdomen, 
it  is  placed  in  the  above  heading.. 

41  The  origin  of  this  symptom  is  obscure.  Its  relationship  to  helminthiasis  is  doubted , 
probably  because  many  children  not  harboring  intestinal  worms  have  the  habit  of  picking 
or  scratching  the  nose.  Nasal  itching,  however,  is  mentioned  by  most  authorities  on  helmin- 
thiasis, and  appears  in  the  statistics  of  Cobbold  and  Hirsch,  on  the  symptoms  of  tapeworm 
infections. 


SCHLOSS!  HELMINTHIASIS  IN  CHILDREN 


699 


IV.  Symptoms  referable  to  the  skin  or  due  to  irritation  of  the  skin 
or  mucous  membranes. 

(A)  Symptoms  referable  to  skin. 

1.  Erythema.  )    .       .  x 

2  Urticaria    J  ^scaris,  tapeworms. 

(B)  Rectal  irritation  (Oxyuris  vermicularis). 

(C)  Genital  pruritus,42  or  irritation,  which  may  lead  to — 

1.  Vulvitis  or  vulvovaginitis.  ^  Usually  in  infections 

2.  Enuresis.  V  with   Oxyuris  ver- 

3.  Masturbation.  )  micularis. 
V.  General  symptoms. 

(^4)  Loss  of  weight. 
(B)  Anemia. 

Blood  Changes.  Miiller  and  Reider,43  in  1891,  and  Zappert,44  in 
1893,  found  an  increase  of  the  eosinophile  cells  in  cases  of  uncinari- 
asis. Following  these  observations,  eosinophilia  has  been  noted  in 
infections  with  many  varieties  of  parasitic  worms.  In  the  case  of 
the  more  common  and  often  harmless  parasites  the  recorded  obser- 
vations show  that  eosinophilia  may  occur,  but  is  inconstant. 

In  the  blood  counts  made  by  Boycott45  in  cases  of  oxyuris  infec- 
tion, about  two-fifths  of  the  cases  showed  an  eosinophilia.  This 
inconstancy  has  been  noted  by  other  observers. 

From  his  studies  on  uncinariasis,  Boycott46  is  of  the  opinion  that 
the  presence  and  degree  of  eosinophilia  is  in  inverse  proportion  to 
the  duration  of  infection.  He  found  in  cases  of  hookworm  infection 
that  the  eosinophilia  gradually  disappeared  without  the  worm 
leaving  the  intestine.  Ashford  and  King,47  in  their  work  on  unci- 
nariasis, found  that  there  was  no  increase  in  the  eosinophile  cells  in 
severe  infections  or  in  those  of  long  standing  associated  with  anemia. 

These  clinical  observations  find  confirmation  in  the  experimental 
work  of  Opie48  on  trichinosis.  This  investigator  administered  esti- 
mated numbers  of  the  encysted  embryos  of  Trichina  spiralis  to 
guinea-pigs,  and  observed  the  effect  of  the  infection  on  the  eosino- 
phile cells.  He  found  that  the  administration  of  a  moderate  number 
of  trichinae  produced  eosinophilia,  but  when  a  severe  infection  was 
induced,  the  eosinophile  cells  decreased  or  disappeared,  and  death 
of  the  animal  ensued. 


42  This  symptom  is  probably  not  always  due  to  local  irritation,  since  it  may  occur 
in  tapeworm  infections.  With  the  larger  tapeworms  the  passage  of  segments  may  be  the 
causative  factor.  This  could  hardly  explain  its  occurrence  in  the  case  of  the  dwarf  tape- 
worm, where  the  segments  are  extremely  small  and  do  not  seem  to  be  regularly  passed. 

43Deut.  Archiv  f.  klin.  Med.,  1891,  xlviii,  96. 

44  Zeitschr.  f.  klin.  Med.,  1893,  xxiii,  227. 

45  Brit.  Med.  Jour.,  1903,  ii,  1267. 

46  Jour.  Hyg.,  1903,  iii,  95;  1904,  iv,  437. 

47  Amer.  Med.,  1903,  vii,  391. 

48  Amur.  Jour.  Med.  Sci.,  1904,  cxxvii,  477. 


700 


SCHLOSS!  HELMINTHIASIS  IN  CHILDREN 


From  the  blood  counts  in  my  cases  it  seems  that  the  occur- 
rence of  eosinophilia  bears  relation  to  the  presence  of  symptoms 
and  to  the  duration  of  infection.  In  other  words,  eosinophilia 
was  generally  absent  in  cases  which  presented  no  symptoms  of 
helminthiasis  (usually,  but  not  always,  light  infections).  Eosino- 
philia was  usually  present  in  cases  which  presented  symptoms,  with 
the  exception  of  severe  or  long-standing  infections.  The  degree  of 
eosinophilia  did  not  seem  to  bear  any  constant  relation  to  the  severity 
of  the  symptoms. 

The  above  statements  are  not  strictly  applicable  to  the  whipworm, 
since  this  parasite  did  not  cause  an  increase  of  the  eosinophile 
cells.  On  the  other  hand,  it  rarely  causes  symptoms.  The  sig- 
nificance of  the  percentages  of  the  eosinophile  cells  found  in  children 
who  harbor  intestinal  worms  is,  obviously,  dependent  on  the  per- 
centages of  these  cells  found  in  normal  children. 

It  is  often  stated  that  in  children  the  normal  percentages  of  the 
eosinophile  cells  are  much  greater  than  those  considered  normal 
for  adults.  The  investigations  of  Carstanjen49  on  children  do  not 
show  that  the  percentage  of  these  cells  is  uniformly  high.  They 
indicate,  however,  that  the  percentages  may  vary  greatly  in  children 
of  the  same  age.  Thus,  in  children  between  four  and  five  years  of 
age,  the  eosinophile  cells  in  one  case  were  0.75  per  cent.,  in  another 
16.65  per  cent.  The  eosinophils  were  above  6  per  cent,  in  16  of 
the  55  children  between  two  and  thirteen  years  of  age.  The  counts 
of  Zappert50  have  practically  the  same  significance;  16  of  the  28 
children  between  two  and  thirteen  years  of  age  showed  an  eosinophilia 
of  more  than  6  per  cent.  In  one  case,  a  child  with  chorea,  the 
eosinophiles  were  19.54  per  cent.  As  shown  in  the  reports  of  these 
writers,  a  number  of  the  children  suffered  from  various  chronic 
disorders,  and  therefore  cannot  be  considered  entirely  normal. 
The  attempt  to  exclude  helminthiasis  is  not  mentioned  in  any  of 
these  investigations,  and  apparently  was  not  made. 

Boycott51  found  the  eosinophile  cells  under  5  per  cent,  in  8  out  of 
10  normal  and  apparently  "wormless"  children.  In  one  case  the 
eosinophile  cells  were  5.2  per  cent.;  in  another,  5.4  per  cent.  I 
have  made  differential  blood  counts  on  20  apparently  normal 
children  who  did  not  harbor  intestinal  worms — judging  from  an 
examination  of  the  feces  (Table  VII) ;  14  of  these  children  appeared 
normal,  and  complained  of  no  symptoms;  6  were  recovering  from 
mild  digestive  disorders.  In  18  cases  the  eosinophile  cells  were 
below  5  per  cent.,  in  1  case  they  were  5  per  cent,  and  in  1  case  6 
per  cent. 

The  possibility  of  an  idiopathic  eosinophilia  in  children  cannot 

«  Jahr.  f.  Kinderheilk,  1900,  lii,  215,  233,  and  684. 
soztschr.  f.  klin.  Med.,  1893,  xxiii,  227. 
m  Brit.  Med.  Jour.,  1903,  ii,  1267. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


701 


be  excluded  on  the  basis  of  this  small  number  of  examinations. 
The  results,  however,  are  of  sufficient  uniformity  to  indicate  that  in 
normal  children — not  harboring  intestinal  worms — the  eosinophile 
cells  are  not  frequently  above  5  per  cent.  This  question,  however, 
is  worthy  of  further  study. 

There  have  been  a  number  of  experiments  which  throw  light  on 
the  cause  of  eosinophilia  in  infections  with  parasitic  worms.  Accu- 
mulation of  eosinophile  cells  in  the  intestinal  wall  has  been  observed 
by  Strong52  and  Yates53  in  postmortem  examinations  of  fatal  cases 
of  uncinariasis.  A  local  accumulation  of  eosinophile  cells  in  the 
muscles  containing  encysted  trichinae  has  been  observed  by  Brown,54 
Opie,55  and  others.  Calamada56  was  able  to  produce  eosinophilia  in 
rabbits  and  guinea-pigs  by  the  injection  of  a  filtered  aqueous  extract 
of  Tenia  saginata. 

Table  VII. — The  Percentage  of  Eosinophile  Cells  in  Apparently 
Normal  Children. 


Age 

Per  cent,  of  eosino- 

No. 

Years. 

phile  cells. 

1*  

.     .     .  2 

5.0 

2t  

...  2 

2.8 

3t  

.     .     .  2 

2.3 

4f  

.     .     .  3 

3.9 

5*  

.     .     .  3 

6.0 

6t  •  

...  3 

4.3 

7*  

.     .     .  5 

3  2 

8t  

.     .     .  5 

0.9 

9t  

.     .     .  5 

3.8 

10*  

.     .     .  5 

2.1 

Ht  

.     .     .  5 

4.7 

12f  

1.2 

13t  

.     .     .  6 

0.8 

0.01 

15*  

.     .     .  8 

3.7 

16t  

.     .     .  8 

4.0 

17t  

0.2 

18t  

...  10 

1.6 

19f  

.     .     .  10 

2.4 

20f  

.     .     .  11 

3.5 

*  Patients  from  private  practice. 

t  Dispensary  patients. 

These  experiments  indicate  that  the  parasites  probably  excrete 
substances  which  have  a  positive  chemotactic  influence  on  the 
eosinophile  cells.  Moreover,  it  is  probable  that  the  eosinophilia 
represents  a  reaction  on  the  part  of  the  organism,  and  that  in 
severe  or  long-standing  infections  the  power  of  producing  eosino- 
phile cells  is  gradually  diminished. 

The  association  of  Charcot-Leyden  crystals  with  eosinophilia  has 
been  observed  in  several  diseases.  These  crystals  frequently  occur 
in  the  feces  in  helminthiasis,  and  their  presence  is  of  considerable 


52  Quoted  by  Opie.  6:5  Johns  Hopkins  Hosp.  Bull.,  1901,  xii,  366. 

64  Jour.  Exper.  Med.,  1898,  iii,  315.  65  Amer.  Jour.  Med.  Scr.,  1904,  cxxvii,  477. 

66  Cent.  f.  Bakt.  u.  Parasit.,  1901,  xxx,  375. 


702 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


diagnostic  value.  Chareot-Leyden  crystals  are  probably  derived 
from  the  eosinophile  cells,  so  that  their  occurrence  in  the  feces  in 
helminthiasis  would  seem  to  represent  a  local  eosinophilia.57 

Biicklers58  has  noted  the  presence  of  Charcot-Leyden  crystals 
in  the  feces  of  cases  of  helminthiasis  showing  eosinophilia.  I 
examined  the  feces  for  Charcot-Leyden  crystals  in  14  cases  with 
eosinophilia,  and  the  result  was  positive  in  the  following:  in 
1  of  6  cases  infected  with  H.  nana,  in  4  of  6  cases  infected  with 
O.  vermicularis,  and  in  both  of  2  cases  infected  with  T.  saginata. 

In  a  number  of  my  cases  the  large  mononuclear  and  tran- 
sitional cells  were  above  the  percentages  usually  given  as  normal. 
The  apparent  increase  in  these  cells  seemed  of  no  especial  signifi- 
cance, and  had  no  relation  to  the  presence  of  symptoms  or  to  the 
severity  of  the  infection.  The  percentage  of  basophile  cells  (mast 
cells)  was  frequently  increased,  and  the  increase  was  greatest  in 
cases  showing  eosinophilia.  This  relationship,  however,  was  not 
constant,  and  the  mast  cells  were  increased  in  several  cases  not 
showing  eosinophilia. 

The  percentage  of  hemoglobin  was  low  in  many  of  the  patients 
who  suffered  from  symptoms.  The  anemia  was  more  pronounced 
in  the  threadworm  and  dwarf  tapeworm  infections. 

Diagnosis.  It  seems  hardly  necessary  to  state  that  it  is  impos- 
sible to  diagnosticate  the  presence  of  intestinal  worms  from  the 
symptoms  produced  in  the  host.  The  symptoms  of  helminthiasis 
are  usually  obscure  and  are  more  often  due  to  other  causes. 

The  presence  of  Tenia  saginata  is  usually  indicated  by  the  passage 
of  segments,  but,  as  previously  shown,  these  may  not  be  observed. 
The  migration  of  oxyurides  and  the  local  symptoms  produced  often 
leads  to  their  detection.  The  presence  of  ascarides  may  be  indicated 
by  the  previous  passage  of  a  worm.  Segments  of  the  dwarf  tape- 
worm are  occasionally  found  in  the  stools,  but  they  are  so  minute 
that  they  can  only  be  recognized  by  means  of  a  lens.  Rarely  the 
intact  worms  may  be  passed  after  the  administration  of  a  cathartic. 
The  whipworm  is  rarely,  if  ever,  found  in  the  stools. 

The  easiest  and  only  satisfactory  diagnostic  method  is  the  exami- 
nation of  the  feces  for  the  parasites,  their  parts,  or  ova.  It  is  best 
to  administer  a  calomel  purge  before  obtaining  the  specimen  for 
examination,  as  by  this  means  oxyuris  is  more  likely  to  be  detected. 
A  number  of  methods  of  examination  have  been  recommended,  but 
I  have  found  the  following  to  be  entirely  satisfactory:  A  small 
portion  of  the  feces  (15  to  20  grams)  is  thoroughly  mixed  with  suffi- 
cient distilled  water  to  make  a  translucent  mixture.  This  is  well 
shaken,  and  a  large  drop  is  placed  on  a  slide  and  covered  with  a 
cover-slip.  By  means  of  the  mechanical  stage  eight  to  ten  prepa- 
rations are  thoroughly  examined.    Two  by  three  inch  slides  and 


67  Limasset,  These  de  Paris,  1901. 


5«  Munch,  med.  Woch.,  1894,  xli,  22  and  47. 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


703 


one  by  two  inch  cover-glasses  are  more  convenient  than  the  ordinary 
size,  as  more  material  can  be  examined  in  a  single  specimen.  In 
conducting  the  microscopic  examination,  a  moderate  illumination 
is  desirable,  and  it  is  best  not  to  use  a  condenser.  Transparent  and 
colorless  ova,  such  as  those  of  the  dwarf  tapeworm,  the  threadworm, 
and  hookworm,  are  likely  to  be  overlooked  if  the  illumination  is  too 
intense. 

It  is  rather  important  that  the  feces  be  thoroughly  mixed,  since 
the  ova  of  parasites  inhabiting  the  upper  intestinal  tract  are  more 
likely  to  be  found  in  the  centre  of  the  fecal  mass,  while  the  ova  of 
other  parasites  are  only  discharged  in  the  large  intestine,  and  in  con- 
sequence are  more  likely  to  be  in  the  external  layer.  Scrapings 
from  the  rectum  frequently  give  positive  results  with  the  thread- 
worm when  the  examination  of  the  feces  is  negative. 

One  finds  rather  frequent  references  to  pseudo-ova,  which  may 
lead  to  confusion.  These  bodies  are  usually  vegetable  cells,  which 
have  a  cell  membrane  and  cellular  or  granular  contents.  After  the 
ingestion  of  some  of  the  common  fruits — oranges,  raspberries, 
bananas,  etc. — these  cells  are  frequently  found  in  the  feces.  Starch 
granules  and  epithelial  cells  may  occasionally  have  a  superficial 
resemblance  to  ova.  Although  these  bodies  may  be  a  source  of 
confusion,  yet  their  resemblance  to  true  ova  is  only  superficial. 
All  danger  of  confusion  is  eliminated  by  familiarity  with  the  appear- 
ance of  the  ova  of  intestinal  worms.  Absolute  verification  of  the 
diagnosis  may  be  obtained  by  recovery  of  the  parasite. 

To  search  for  parasites  the  feces  should  be  well  diluted  and 
poured  into  a  flat  vesesl,  the  bottom  of  which  has  been  painted  black. 
By  this  means  the  worms  can  be  easily  recognized,  and  their  species 
determined  by  microscopic  examination. 

If  further  argument  were  needed  to  show  the  importance  of 
examining  the  feces  for  ova,  it  is  only  necessary  to  recall  my 
statistics.  The  parasites  which  rank  first  (the  whipworm)  and 
third  (the  dwarf  tapeworm)  in  frequency  are  never  observed  by  the 
patients,  but  can  only  be  detected  by  finding  the  ova  on  microscopic 
examination  of  the  feces. 

Prophylaxis.  With  the  exception  of  Tenia  saginata,  infection 
with  the  parasites  dealt  with  in  this  paper  results  from  the  ingestion 
of  ova.  Infection  with  Tenia  saginata  occurs  from  ingestion  of 
so-called  "measley  beef,"  that  is,  meat  containing  the  cysticercus 
stage  of  this  parasite.  The  tongue  and  muscles  of  mastication 
most  often  contain  the  cysticerci.  The  exclusion  of  all  infected 
meat  by  rigid  inspection  is  the  best  preventive  measure.  Heat 
destroys  the  embryos,  and  thorough  cooking  of  infected  meat  will 
render  it  harmless.  To  prevent  infection  with  the  other  parasites, 
it  is  important  that  infected  cases  should  be  thoroughly  and  promptly 
treated.  Measures  should  be  taken  to  prevent  contamination  of 
the  water  supply  with  the  ova.    To  prevent  infection  of  other 


704 


SCHLOSS:  HELMINTHIASIS  IN  CHILDREN 


members  of  the  family,  rigid  cleanliness  should  be  observed,  and 
the  contamination  of  food  or  hands  with  the  feces  of  infected  persons 
guarded  against.  An  experiment  of  Stiles59  indicates  that  flies  may 
be  the  carriers  of  the  ova  of  the  eelworm  of  hogs — a  parasite  closely 
related  to  the  eelworm  of  man.  It  is  possible  that  infection  with 
the  human  parasite  may  be  disseminated  in  this  manner.  The 
prophylaxis  is  obvious.  It  is  possible  that  infection  with  the  dwarf 
tapeworm  may  result  from  contamination  of  food  with  the  feces 
of  rats  or  mice  infected  with  this  worm.  This  gives  another  indica- 
tion for  the  extermination  of  rats  and  mice.  To  prevent  the  spread 
of  intestinal  worms,  it  is  only  necessary  to  remember  that  the  feces 
of  those  infected  usually  contain  great  numbers  of  the  ova,  and  that 
the  ingestion  of  a  single  ovum  may  lead  to  the  development  of  an 
intestinal  worm. 

Summary.  1.  Twelve  of  30  children  who  suffered  from  un- 
explained nervous  or  gastro-intestinal  symptoms  were  found  to 
harbor  intestinal  worms. 

2.  Consecutive  examinations  of  280  children  showed  that  80 
(28.57  per  cent.)  harbored  intestinal  worms.  Five  of  the  children 
harbored  two  species  of  parasite,  giving  a  total  of  85  infections. 

3.  Thirty-one  (11.07  per  cent.)  of  the  children  harbored  Trichuris 
trichiura,  23  (8.21  per  cent.)  harbored  Oxyuris  vermicularis,  20 
(7.14  per  cent.)  harbored  Hymenolepis  nana,  6  (2.14  per  cent.) 
were  infected  with  Ascaris  lumbricoides,  and  5  (1.78  per  cent.)  with 
Tenia  saginata. 

4.  Only  1  of  33  children  infected  with  Trichuris  trichiura  (from 
both  groups  of  examinations)  suffered  from  symptoms. 

5.  Thirty-five  of  the  51  children  infected  with  the  other  parasites 
(from  the  consecutive  examinations)  suffered  from  symptoms. 

6.  The  eosinophile  blood  cells  were  not  increased  in  cases  infected 
with  Trichuris  trichiura. 

6.  In  infections  with  the  other  parasites  eosinophilia  was  usually 
absent  when  there  were  no  symptoms  due  to  helminthiasis.  Eosino- 
philia was  generally  present  in  cases  which  presented  symptoms  of 
helminthiasis. 

Conclusions.  1.  Intestinal  parasites  are  not  infrequent  among 
the  children  of  the  poorer  classes  of  New  York  City. 

2.  Intestinal  worms  may  be  harbored  without  inconvenience  to  the 
host.  On  the  other  hand,  symptoms  may  occur  which  are  always 
deleterious,  and  sometimes  severe. 

These  investigations  were  made  on  patients  from  the  clinic  of 
Dr.  Thomas  S.  Southworth  at  the  out-patient  department  of  the 
Babies'  Hospital,  and  from  the  service  of  Dr.  Eli  Long,  at  the  New 
York  University  and  Bellevue  Hospital  Medical  College.  I  desire 
to  express  my  appreciation  for  this  privilege  and  for  encouragement 


59  Modern  Medicine,  Osier  and  McCrae,  1907,  i,  597. 


neuhof:  an  epidemic  of  noma 


705 


in  carrying  out  the  work.  I  wish  to  acknowledge  my  indebtedness 
to  Miss  Eleanor  Ketcham,  visiting  nurse  to  the  children's  clinic  of 
the  New  York  University  and  Bellevue  Hospital  Medical  College, 
for  valuable  assistance  in  obtaining  material  and  in  following  the 
cases. 


AN  EPIDEMIC  OF  NOMA 

By  Harold  Neuhof,  M.D., 

ADJUNCT   SURGEON   TO   THE    NEW   YORK   HEBREW   INFANT  ASYLUM. 

Through  the  kindness  of  Dr.  Jonas  E.  Reinthaler  and  Dr. 
Charles  A.  Elsberg,  respectively  attending  physician  and  surgeon 
to  the  New  York  Hebrew  Infant  Asylum,  I  had  the  opportunity  of 
studying  an  epidemic  of  noma  which  occurred  in  that  institution 
in  the  spring  of  1909.  The  asylum  is  a  substantial,  well-preserved 
edifice.  It  was  originally  a  private  dwelling,  and  was  later  enlarged 
by  the  addition  of  wings.  The  institution  accommodates  about 
150  children.  During  the  epidemic  there  were  140  children  in  the 
asylum  of  varying  ages,  up  to  six  years. 

Three  cases  of  noma  occurred  in  the  asylum  during  fourteen  years, 
one  in  November,  1902,  one  in  February,  1907,  and  one  in  February, 
1908.  All  three  patients  died;  in  two  the  treatment  was  conserva- 
tive; in  the  third  and  last  a  wide  excision  was  performed  by  Dr. 
Elsberg.  In  the  three  cases  the  disease  developed  in  the  course  of 
epidemics  of  measles  complicated  by  ulcerative  stomatitis.  It  is  of 
interest  that  the  three  cases,  though  widely  separated  in  time, 
occurred  in  the  same  ward — a  sunny,  well-ventilated  room. 

The  epidemic  of  noma  of  1909  complicated  an  epidemic  of  measles, 
which  spread  in  the  institution  despite  careful  isolation  of  all  the 
exposed  children.  The  epidemic  of  measles  was  a  severe  one  and 
complications  were  frequent.  There  were  81  cases — of  which  13 
developed  diphtheria,  and  24  pneumonia — with  a  mortality  (exclu- 
sive of  noma)  of  4  per  cent.  Although  special  attention  was  paid  to 
the  mouths,  ulcerative  stomatitis  occurred  in  fully  25  per  cent,  of 
the  children,  and  it  was  among  these  children  that  most  of  the 
cases  of  noma  developed.  There  were  8  cases  of  true  noma  and  3 
doubtful  ones,  to  which  reference  will  later  be  made. 

One  of  the  most  striking  facts  about  noma  is  that  it  has  formerly 
broken  out,  almost  invariably,  in  overcrowded  and  ill-regulated 
hospitals.  For  example,  Saviard  and  Poupart1  recorded  epidemics 
of  noma  in  the  old  Hotel  Dieu  in  Paris  under  such  circumstances; 
in  the  new  institution  the  disease  did  not  develop.  There  are  many 
similar  reports  in  the  literature  of  the  disease.    On  the  other  hand, 

1  Trans.  Med.  Chir.  Soc,  Edinburgh,  1892-9,  xii,  251. 


706 


neuhof:  an  epidemic  of  noma 


in  recent  years  epidemics  have  broken  out  in  excellent  institutions, 
as  in  that  reported  by  Blumer  and  McParlane2  and  in  that  of  Crandon, 
Place,  and  Brown.3 

The  association  of  noma  with  the  infectious  diseases — especially 
measles  and  pertussis — is  well  known.  The  pronounced  tendency 
for  noma  to  appear  in  the  spring  and  fall  may  depend  upon  the 
greater  frequency  of  the  infectious  diseases  in  those  seasons.  There 
is  no  conclusive  proof  that  the  disease  is  contagious.  Mayr4  believes 
in  its  contagiousness;  Holt5  is  of  the  same  opinion,  as  he  has  seen  5 
cases  of  noma,  after  whooping  cough,  develop  in  the  same  ward. 
Of  the  cases  in  our  epidemic,  2  developed  in  one  ward,  3 
appeared  in  another,  and  5  (including  the  three  not  proved) 
developed  in  a  third  ward,  which  was  reserved,  as  far  as  possible, 
for  all  of  the  cases  of  stomatitis.  A  single  case  developed  in  the 
isolation  house  to  which  the  child,  suffering  from  diphtheria,  had 
been  transferred.  Two  of  the  wards  were  on  the  same  floor,  the 
third  was  on  another.  Each  ward  was  carefully  isolated,  had  its 
special  nurses,  separate  food,  dishes,  etc.  The  children  who  devel- 
oped noma  were  transferred  to  the  isolation  house  as  soon  as  the 
disease  appeared.  It  is  often  impossible  to  say  when  noma  is 
developing,  and  undoubtedly  many  children  were  exposed  to  the 
disease  when  they  were  presumably  in  a  receptive  condition — suffer- 
ing from  measles  and  ulcerative  stomatitis.  With  these  conditions, 
favorable  for  the  spread  of  a  contagious  disease,  only  a  few  of  the 
little  patients  were  attacked  by  noma,  and  no  connection  could  be 
demonstrated  between  the  isolated  cases.6 

Noma  may  appear  at  any  age  and  among  all  cases  of  patients. 
The  large  majority  of  the  cases  have  occurred  among  poorly  nour- 
ished children7  during  the  first  and  second  dentition,  and  many  appar- 
ently developed  from  ulcers  around  the  teeth.  Rilliet  and  Barthez,8 
in  their  classic  description  of  the  disease,  describe  noma  in  infants 
at  the  breast.  Inasmuch  as  noma  so  often  follows  ulcerative 
stomatitis,  many  writers  (Eichhorst,9  Henoch,10  Guizetti,11  Seiffert,12 
etc.  )  consider  noma  an  advanced  stage  of  stomatitis.  They  point 
out  that  at  first  it  is  a  purely  local  disease,  that  the  same  organisms 

2  Amer.  Jour.  Med.  Sci.,  1901,  cxxii. 

3  Boston  Med.  and  Surg.  Jour.,  April  15,  1909. 

4  Zeitschr.  der  Kais.-Kon.  Gesellsch.  der  Aerzte  zu  Wien,  1852. 

5  Diseases  of  Infancy  and  Childhood,  1905,  pp.  290,  692. 

6  Schmorl  (Zeitschr.  f.  Thiermed.,  1891,  p.  375)  described  an  epidemic,  among  rabbits,  of 
gangrene  beginning  in  the  mouth,  which  was  very  similar  to  noma.  He  showed  that  it  was 
contagious. 

7  Some  of  these  cases  in  the  literature  described  as  noma  in  adults  correspond  very  closely 
to  cases  of  leukemia  with  terminal  gangrenous  ulceration  in  the  mouth.  Blood  examinations 
were  not  recorded. 

s  Traite  des  Malad.  des  Enfants,  1852,  p.  62. 
9  Specielle  Patholog.  und.  Therap. 
Jo  Trans.  Chicago  Path.  Soc,  1896,  i,  252.  j 

11  II  Policlinico,  1899. 

12  Munch,  med.  Woch.,  1901. 


nfajhof:  an  epidemic  of  noma 


707 


are  found  in  the  smears  taken  from  the  ulcers  of  both  diseases,  and 
that  the  transition  from  the  one  condition  to  the  other  has  been 
observed.  It  will  be  shown  below  that  a  definite  bacteriological 
picture  is  found  in  noma  and  not  in  ulcerative  stomatitis. 

There  are  usually  no  constitutional  symptoms  until  the  gangrene 
has  begun  to  spread.  The  child  is  usually  quiet  and  languid,  but 
may  be  very  restless  and  irritable.  Often  it  is  profoundly  prostrated, 
but  may  feel  well  enough  to  sit  up  in  bed  and  play,  although  the 
gangrene  is  spreading  over  its  face.  Marked  pallor  is  an  early 
symptom.  The  pulse  soon  becomes  rapid  and  small;  there  is 
slight  or  no  tever,  and  generally  no  pain.  Thirst  is  marked, 
although  the  tongue  is  moist.  Diarrhoea  is  often  a  serious  symptom, 
but,  according  to  some  observers,  occurs  only  when  gangrenous 
material  is  swallowed.13  Bronchopneumonia  is  the  most  frequent 
and  fatal  complication.  It  is  of  the  aspiration  type,  and  not  un- 
commonly leads  to  abscess  or  gangrene  of  the  lung. 

Of  the  physical  signs,  the  ulcer  is  usually  the  first  lesion  observed 
(Bohn,14  Eichhorst,  Osier,15  etc.).  Billroth,  however,  describes  a 
nodule  in  the  cheek  as  the  starting  point,  and  Fagge16  believes  the 
disease  begins  immediately  under  the  mucous  membrane.  The 
necrotic  ulcer  becomes  gangrenous,  the  adjoining  portion  of  the 
cheek  becomes  intensely  infiltrated,  and  the  gangrene  extends  to  it 
and  often  to  the  adjacent  maxilla.  The  peculiarly  penetrating  foul 
odor  from  the  mouth  is  at  the  beginning  faint,  yet  it  may  be  the  first 
sign  to  call  attention  to  the  disease.  As  the  overlying  skin  becomes 
involved,  it  assumes  a  violaceous  hue,  later  turns  black  and  is  covered 
with  vesicles;  finally  the  gangrenous  ulcer  breaks  through.  Tourdes17 
describes  three  stages  of  the  disease:  (1)  Ulceration  of  the  mucous 
membrane,  cedema  of  the  face,  infiltration  of  the  cheek,  lasting  two 
or  three  days;  (2)  gangrene,  lasting  five  to  twelve  days;  and  (3)  the 
period  of  general  infection.  Rarely  the  disease  runs  a  subacute 
course  over  several  months.  Finally,  Gierke  noted  that  noma  may 
recur.18 

In  a  large  number  of  cases  collected  from  the  literature  the 
mortality  ranged  from  70  to  100  per  cent. 

Many  different  kinds  of  treatment  have  been  recommended. 

13  Several  autopsies  have  shown  a  gangrenous  condition  of  the  gastro-intestinal  tract. 
In  8  cases  of  noma  of  the  genitalia  and  of  the  external  ear  observed  by  Gierke  (Jahrb.  f 
Kinderheilk.,  1868,  p.  65)  diarrhoea  was  present  in  only  one  case,  and  then  it  was  of  short 
duration. 

14  Gerhardt's  Handb.  der  Kinderk.,  iv. 

15  Practice  of  Medicine,  1905. 

16  Amer.  System  of  Diseases  of  Children. 

17  These  de  Strassbourg,  1848. 

18  In  20  cases  he  observed  three  recurrences — one  four  weeks  after  the  discharge  of  necrotic 
tissue,  a  second  case  six  months  after  the  first  attack,  the  third  case  after  three  years.  Babes 
and  Zambilovici  (Annal.  de  l'Instit.  de  Path,  et  de  Bact.  de  Bucarest,  1895,  v)  refer  to  several 
cases. 


708 


neuhof:  an  epidemic  of  noma 


Some  writers  advise  applications  of  alcohol  or  hydrogen  peroxide, 
or  potassium  chlorate,  nitric  acid,  etc.  Others  advise  cauterization 
of  the  ulcer  with  the  actual  cautery;  still  others  practise  excision  of 
the  diseased  area.  No  matter  what  the  treatment  employed,  only 
isolated  cases  have  recovered.  It  is  important  to  make  frequent 
cultures  from  the  necrotic  areas,  as  diphtheria  may  closely  simulate 
true  noma.19  If  there  is  any  doubt  as  to  the  diagnosis,  antitoxin 
should  be  given. 

The  bacteriology  of  noma  rests  on  a  definite  basis  since  1899, 
when  Perthes20  and  Seiffert21  independently  described  a  bacterium 
or  group  of  bacteria  in  this  disease.  Although,  up  to  the  present 
time,  Koch's  laws  have  not  been  fulfilled22  the  disease  has  not  been 
experimentally  reproduced  and  the  bacteria  have  not  been  artificially 
cultivated — the  constant  presence  of  the  bacteria  in  noma,  and  only 
in  this  disease,  points  very  strongly  to  an  etiological  relationship. 
Perthes  found  that  noma  is  due  to  a  fungus-like  growth  belonging 
to  the  streptothrix  group.  At  the  border  line  between  the  gangren- 
ous ulcer  and  normal  tissue  he  found  a  thick  branching  network 
of  fine  fusiform  threads — mycelium.  From  this  mycelium  single 
fine  rods  and  spirilla  extend  into  the  normal  tissue,  surround  the 
cells,  and  cause  their  death.23  Krahn  believes  that  the  growth 
described  by  Perthes  consists  of  two  organisms — the  spirillum 
sputigenum  and  spirochete  dentium.24  The  majority  of  observers 
agree  with  Perthes  and  Seiffert.  The  same  bacteriological  picture 
was  described  in  noma  of  other  parts  of  the  body  by  Matzenauer.25 
Perthes  prepared  his  specimens  for  examination  by  treating  the 
teased  tissue  or  section  from  the  edge  of  the  ulcer — removed  post 

19  Hektoen,  in  the  discussion  on  Bishop  and  Ryan's  paper  before  the  Chicago  Pathological 
Society,  pointed  out  the  close  clinical  correspondence  between  their  cases  of  noma  and  cases 
of  gangrene  of  the  skin  in  which  the  Klebs-Loeffler  bacillus  is  found.  And  Loeffler,  at  a 
meeting  of  the  Greifswald  Medizinische  Verein,  in  1890,  called  attention  to  the  similarity 
between  pathological  specimens  from  cases  of  noma,  shown  by  Grawitz  (Deut.  med.  Woch., 
1890)1  and  diphtheria  in  calves  (Kalberdiphtherie)  that  he  had  observed. 

2"  Arch.  f.  klin.  Chir.,  1899,  lix. 

21  Munch,  med.  Woch.,  1901. 

22  Hofman  and  Kiister  (Munch,  med.  Woch.,  1904,  1907)  found  abscesses  in  animals  after 
the  bacteria  were  injected  and  found  the  same  bacteria  in  the  abscesses.  Furthermore,  they 
obtained  (impure)  anaerobic  growths  of  the  organism.  Neither  of  these  observations  has  been 
subsequently  substantiated. 

23  Ranke  (Jahrb.  f.  Kinderheilk.,  1888,  xxvii)  and  others  have  advanced  evidence  to  show 
that  the  death  of  the  cells  is  due  to  chemical  influences. 

24  Miller  (Microorganisms  of  the  Human  Mouth,  1890)  has  shown  that  these  two  organisms 
are  normal  inhabitants  of  the  mouth,  in  small  numbers.  As  all  attempts  at  their  cultivation 
have  failed,  he  considers  them  parasites  that  cannot  be  separated  from  their  hosts.  In  all 
forms  of  stomatitis,  as  well  as  in  oral  noma,  these  bacteria  are  present  in  enormous  numbers 
in  scrapings  from  the  lesions.  The  fusiform  '  'bacillus"  of  Vincent  is  also  found  on  the  surface 
of  these  ulcers.  But  it  has  not  been  demonstrated  that  any  of  these  organisms  are  related  to 
the  streptothrix  found  in  the  tissues  in  noma,  although  some  of  the  terminal  filaments  of  the 
streptothrix  resemble  them  closely  (see  Migula's  (System  der  Bacterien,  1900)  classification 
of  these  organisms). 

«  Archiv.  f.  Dermat.  und  Syph.,  1902. 


neuhof:  an  epidemic  of  noma 


709 


mortem — with  dilute  carbol-fuchsin  for  twenty-four  hours  and  then 
briefly  washing  with  alcohol.26 

The  clinical  and  bacteriological  pictures  of  the  cases  of  noma  in 
our  epidemic  correspond  in  good  part  with  the  description  given 
above.  However,  some  features  of  importance  in  our  cases  warrant 
a  description  of  them  in  some  detail;  the  detail  of  the  spread  of 
gangrene,  the  appearance  of  the  streptothrix  in  individual  cases,27 
etc.,  will  be  omitted.  By  "conservative"  treatment  we  mean  topical 
applications  of  peroxide  of  hydrogen,  pure  alcohol,  and  potassium 
chlorate;  by  "radical"  treatment,  thorough  cauterization  of  the 
ulcer  and  of  adjoining  tissue  with  the  actual  cautery. 

Case  I. — Measles;  ulcerative  stomatitis;  noma  of  the  vulva; 
recovery. 

Jennie  W.,  aged  two  years,  was  always  delicate.  Bilateral  chronic 
otitis  media.  Measles  March  9,  1909,  complicated  by  a  severe 
ulcerative  stomatitis.  The  latter  cleared  up  except  for  one  ulcer. 
This  necrotic  area  became  gangrenous  in  its  centre.  A  specimen 
removed  did  not  show  the  streptothrix  of  noma.  On  March  17  a 
grayish  membrane  was  observed  covering  the  vulva  and  extending 
over  the  labia  minora  and  across  the  perineum  to  the  rectum.  Cul- 
tures for  diphtheria  were  negative;  antitoxin  had  no  effect.  The 
membrane  spread,  the  affected  area  became  necrotic  in  forty-eight 
hours,  and  there  was  a  profuse  discharge  of  a  gangrenous  odor  from  the 
vagina  and  rectum.  A  specimen  removed  from  the  edge  of  the  ulcer 
showed  the  streptothrix  of  noma.  After  two  weeks,  during  which 
period  the  child  was  profoundly  prostrated,  the  discharge  diminished 
and  the  ulcer  assumed  a  healthier  appearance.  Although  there  was 
a  considerable  loss  of  tissue,  little  deformity  remained  when  healing 
was  complete.  Treatment  was  conservative.  During  convales- 
cence the  ulcer  in  the  mouth  slowly  healed. 

Case  II. — Measles,  ulcerative  stomatitis;  diphtheria  of  the  vulva; 
oral  noma;  recovery. 

Marie  F.,  aged  two  and  a  half  years;  was  always  well  and  strong. 
On  March  10  measles  developed,  in  the  course  of  which  ulcerative 
stomatitis  appeared.  March  16,  a  membrane  was  first  noticed  on 
the  vulva  similar  to  that  in  the  first  case.  Cultures  showed  Klebs- 
Loeffler  bacilli;  the  membrane  disappeared  after  antitoxin  injections. 
As  the  ragged  sloughing  ulcers  about  the  teeth  showed  no  signs  of 

26  Weaver  and  Tunnicliff  (Jour.  Infec.  Dis.,  1907)  demonstrated  that  this  streptothrix  is 
decolorized  by  Gram's  method.  They  obtained  the  best  staining  reactions  by  dropping  n 
10  per  cent,  saturated  solution  of  alcoholic  gentian  violet  in  5  per  cent,  phenol  on  the  sectioa 
(that  had  been  embedded  in  paraffin,  treated  with  xylol,  followed  by  absolute  alcohol)  for  five 
minutes,  clearing  with  aniline  oil,  washing  with  xylol,  and  mounting  in  balsam.  A  complete 
bibliography  of  noma  is  given  by  Weaver  and  Tunnicliff,  Journal  of  Infectious  Diseases,  Janu- 
ary, 1907. 

27  The  streptothrix  stained  very  well  in  our  cases  with  the  simple  method  of  Perthes.  I 
obtained  the  specimens  by  removing  a  small  wedge  of  tissue  from  the  edge  of  the  ulcer,  employ- 
ing small  straight  scissors  and  forceps.    A  tonsillar  "punch"  may  be  employed  to  advantage. 


710 


neuhof:  an  epidemic  of  noma 


healing,  they  were  cauterized  with  the  actual  cautery  on  March  25. 
Following  this  all  but  one  of  the  ulcers  healed.  The  latter  was 
situated  near  the  right  upper  canine  tooth;  a  section  removed 
from  it  showed  the  streptothrix  of  noma.  Treatment  consisted  of 
cauterization  every  second  day.  April  8,  infiltration  of  the  upper 
lip;  ulcer  much  larger;  superior  maxilla  exposed;  overlying  skin 
bluish.  General  condition  good;  slight  fever  and  prostration. 
After  fragments  of  the  necrotic  superior  maxilla  had  separated, 
improvement  began.  The  violaceous  hue  of  the  skin  disappeared; 
the  infiltration  softened;  and  finally  the  slough  separated  from  the 
ulcer.  A  specimen  removed  at  this  time  showed  numerous  spindle- 
shaped  rods  extending  into  normal  tissue,  but  no  mycelium.  The 
treatment  was  conservative  from  the  time  the  gangrene  began  to 
spread. 

Case  III. — Measles;  diphtheria;  oral  noma;  recovery. 

Isidor  L.,  aged  two  years,  had  been  previously  well  and  strong. 
Measles  March  18,  complicated  by  faucial  diphtheria.  The  mem- 
brane disappeared  a  few  days  after  antitoxin  injections.  About 
one  week  later  an  ulcer  appeared  about  the  upper  incisors.  Despite 
several  cauterizations,  it  spread  until  a  large  piece  of  necrotic  maxilla 
was  exposed.  Treatment  by  cauterization  was  then  stopped.  A 
specimen  removed  showed  the  typical  streptothrix.  The  upper  lip 
became  exceedingly  firm  and  infiltrated,  but  the  skin  remained  un- 
changed. During  a  period  of  ten  days  this  condition  was  stationary; 
the  child  was  listless  and  apathetic,  he  had  no  fever,  pulse  was 
rapid.  Then  a  large  fragment  of  necrotic  maxilla  became  detached 
and  was  removed.  Thereafter  the  local  and  general  condition 
improved.  Treatment  was  conservative  after  the  spread  of  the 
ulcer.    Little  deformity  remained  after  healing  was  complete. 

Case  IV. — Measles;  pneumonia;  oral  noma;  death. 

Doris  A.,  aged  three  years,  was  always  pale  and  weakly.  Entero- 
colitis in  1907,  with  recurrences  from  time  to  time.  Measles  March  8, 
complicated  by  a  severe  pneumonia.  On  March  17  an  ulcer  was 
seen  on  the  mucous  membrane  of  the  right  cheek.  Cultures  nega- 
tive; antitoxin  without  effect;  characteristic  odor  from  the  mouth. 
The  cheek  became  indurated  very  rapidly,  the  overlying  skin 
assumed  the  typical  color,  the  ulcer  spread  to  the  vermilion  border 
of  the  lip.  The  child  died  March  21,  apparently  overcome  by 
toxemia.  The  treatment  was  conservative.  A  specimen  was  not 
removed. 

Case  V. — Measles;  diphtheria;  ulcerative  stomatitis;  oral  noma; 
death. 

Harry  S.,  always  well  and  strong.  Measles  March  12;  tonsillar 
diphtheria  March  19.  The  latter  yielded  to  antitoxin  injections. 
A  mild  form  of  stomatitis  was  present.  On  March  23  a  ragged  ulcer 
appeared  below  the  lower  central  teeth,  where  there  had  been  no 
previous  lesion.    A  section  showed  the  streptothrix  of  noma.  Thor- 


NEUHOF:  AN  EPIDEMIC  OE  NOMA 


711 


ough  cauterization  was  practised;  the  next  day  the  adjoining  maxilla 
was  exposed  and  the  submaxillary  region  was  infiltrated.  On 
March  25  an  ulcer  appeared  about  the  teeth  of  the  upper  jaw 
exactly  opposite  the  gangrenous  lesion  of  the  lower — apparently  a 
contact  infection.  It  spread  rapidly,  and  the  eyelids  and  lip  became 
puffy;  an  offensive  discharge  issued  from  the  nostrils.  The  upper 
lesion  spread  more  rapidly  than  the  lower.  Temperature  ranged 
from  100°  to  104°;  pulse  very  rapid  and  small.  The  gangrenous 
ulcers  finally  perforated  the  skin  over  the  chin  and  over  the  upper 
lip;  pus  appeared  in  the  diarrhceal  stool;  the  patient  succumbed 
March  30. 

Case  VI. — Measles;  pneumonia;  ulcerative  stomatitis;  diphtheria; 
oral  noma;  death. 

Daniel  B.,  aged  three  years;  always  ailing  and  on  special  diet 
for  a  year.  Measles  March  14;  shortly  after,  a  severe  ulcerative 
stomatitis.  Pneumonia  with  moderate  prostration;  convalescent 
by  March  20.  Faucial  diphtheria  on  March  21,  yielding  to  anti- 
toxin injections.  On  March  23  an  ulcer  was  first  noted  on  the  inner 
surface  of  the  left  cheek;  at  the  same  time  a  faintly  gangrenous 
odor  of  the  breath  was  observed.  A  section  removed  showed  the 
lesion  of  noma.  Although  the  ulcer  was  thoroughly  cauterized,  it 
spread  and  the  overlying  skin  became  necrotic;  perforation  occurred 
two  days  before  death.  The  latter  occurred  on  April  3  from  a  septic 
bronchopneumonia.  This  patient  suffered  considerable  pain — 
an  exceptional  feature  in  our  cases. 

Case  VII. — Measles;  ulcerative  stomatitis;  oral  noma;  de  th. 

Eddie  A.,  aged  two  and  a  half  years;  was  always  strong  and  well- 
nourished.  Measles  appeared  March  6,  complicated  by  ulcerative 
stomatitis  of  moderate  severity.  On  March  18  an  ulcer  was  first 
seen  in  the  normal  mucous  membrane  along  the  frenum  linguae. 
With  daily  deep  cauterization,  this  ulcer  remained  stationary, 
whereas  the  ulcers  surrounding  the  teeth  healed.  A  section  taken 
from  the  sublingual  lesion  showed  the  streptothrix  of  noma;  one 
removed  from  one  of  the  other  ulcers  did  not.  On  April  1  the 
ragged  ulcer  under  the  tongue  began  to  spread  on  the  surface  and 
into  the  depths.  It  became  gangrenous,  spread  over  the  whole  floor 
of  the  mouth,  and  caused  a  marked  induration  in  the  submaxillary 
region.  On  April  4  an  ulcer  under  the  upper  lip  appeared,  opposite 
the  lower  ulcer.  It  spread  more  rapidly  than  the  original  lesion. 
April  7,  gangrene  of  the  skin  over  both  ulcers.    Death  on  April  9. 

Case  VIII. — Measles;  ulcerative  stomatitis;  oral  noma;  death. 

David  R.,  aged  two  and  a  half  years;  always  ailing  and  weakly. 
Had  measles  March  17,  complicated  by  mild  ulcerative  stomatitis. 
March  22,  apparently  on  the  base  of  one  of  the  ulcers  about  the 
lower  central  incisors  there  was  a  large  deep  ulcer.  A  specimen 
showed  the  streptothrix.  The  ulcer  was  frequently  cauterized,  and 
did  not  grow  larger  until  April  4.    It  then  began  to  spread,  so  that 


712 


netthof:  an  epidemic  of  noma 


by  April  7  the  chin  was  swollen  and  shiny.  The  next  day  a  contact  (  ?) 
lesion  appeared  on  the  upper  gums  and  spread  like  the  primary 
ulceration.  A  specimen  removed  showed  the  same  pathological 
picture  as  that  from  the  lower  lesion.  The  skin  of  the  chin  became 
gangrenous,  and  soon  after,  gangrene  of  the  upper  lip  developed. 
The  patient  died  April  11;  he  was  not  prostrated  until  twenty-four 
hours  before  death. 

In  the  last  three  cases  frequent  cauterization  was  employed  after 
the  ulcers  had  begun  to  spread,  in  order  to  determine  its  value  in 
this  stage  of  the  disease.  This  radical  treatment  had  no  salutary 
effect  on  the  lesion;  if  anything,  it  appeared  to  hasten  the  spread 
of  the  gangrene. 

To  these  undoubted  cases  of  noma  I  would  add  the  three  cases 
to  which  reference  has  already  been  made.  All  three  patients  had 
measles,  and  in  two  of  them  ulcerative  stomatitis  developed.  In 
both  the  stomatitis  cleared  up  with  the  exception  of  one  ulcer.  In  the 
third  case  there  was  a  single  ulcer  from  the  outset.  The  ulcer,  in 
each  case,  was  deep,  ragged,  and  necrotic,  identical  with  the  ulcer 
observed  in  the  pregangrenous  stage  of  noma.  Specimens  taken 
from  the  edge  of  the  ulcer  showed  in  each  case  the  streptothrix  of 
Perthes.  The  ulcers  were  submitted  to  frequent  and  thorough 
cauterizations,  and  after  a  period  of  two  to  four  weeks  they  healed 
without  any  spread  of  necrosis  and  without  the  development  of 
serious  constitutional  symptoms. 

Among  the  patients  with  stomatitis  there  were  several  who  had 
very  suspicious  ulcers.  Specimens  removed  did  not  show  the 
streptothrix,  and  none  of  these  patients  developed  noma. 

It  will  have  been  noted  that  for  the  cauterizations  and  for  the 
removal  of  specimens  no  anesthesia  was  employed.  This  was  done 
for  the  following  reasons:  In  the  first  place  the  manipulations  may 
be  carried  out  quite  painlessly.  In  the  second  place,  these  children 
are  already  much  weakened  by  their  disease,  and  the  function  of  their 
lungs  is  impaired  by  the  associated  pulmonary  affection;  in  them  a 
general  anesthesia  must  certainly  be  very  dangerous.  In  not  a 
few  of  the  patients  who  were  operated  upon  under  general  anesthesia 
septic  pneumonia  followed. 

In  Cases  II,  VII,  and  VIII,  the  spread  of  gangrene  was  delayed 
about  two  weeks,  in  each  case,  by  repeated  cauterizations,  and  I 
believe  that  if  cauterization  had  been  begun  earlier,  the  spread  of 
noma  might  have  been  much  longer  delayed.  It  cannot,  of  course, 
be  proved  that  the  three  cases  of  ulcer  identical  clinically  and  histo- 
logically with  the  pregangrenous  ulcer  of  noma  were  really  cases  of 
noma  aborted  by  radical  treatment;  the  findings,  however,  all  point 
in  that  direction.  It  appears  to  me,  from  our  experience,  that  the 
radical  treatment  is  of  value  only  in  the  pregangrenous  stage  of 
noma.  We  have  found  the  streptothrix  in  this  stage,  and  hence  have 
concluded  that  it  is  unnecessary  to  wait  for  the  appearance  of  gan- 


neuhop:  an  epidemic  op  noma 


713 


grene  in  order  to  institute  radical  treatment.  As  before  stated, 
actual  cauterization  is  as  effectual  as  excision  and  is  less  mutilating. 

The  close  association  of  noma  with  ulcerative  stomatitis  was 
seen  in  this  epidemic.  Ulcerative  stomatitis  of  varying  severity  was 
present  in  8  of  the  11  patients;  in  some  of  the  cases  the  ulcers 
were  necrotic,  almost  gangrenous.  Yet  in  only  one  (Case  VIII) 
did  it  seem  probable  that  noma  had  developed  on  one  of  the  lesions 
of  ulcerative  stomatitis.  From  the  observation  of  all  the  cases  in 
this  epidemic,  and  from  the  microscopic  studies,  we  must  conclude 
that  disease  of  the  mouth  prepared  a  favorable  soil  for  the  develop- 
ment of  noma,  but  that  there  was  no  evidence  of  a  direct  etiological 
connection  between  stomatitis  and  noma. 

What  significance  should  be  attached,  in  Cases  V,  VII,  and  VIII, 
to  the  development  of  gangrenous  ulcers — apparently  by  contact — 
cannot  be  determined.  Such  a  path  of  transmission  of  the  disease 
would  seem  probable;  it  occurred  in  three  of  our  five  fatal  cases. 
In  one  of  these  patients  the  microscopic  examination  revealed  the 
streptothrix  in  sections  from  the  second  ulcer.  I  have  been  unable 
to  find  any  mention  in  the  literature  of  second  ulcers  in  noma.28 

Conclusions.  Noma  usually  appears  in  epidemic  form;  its 
contagiousness  has  not  been  proved.  The  disease  is  an  entity,  and 
not  a  later  stage  of  ulcerative  stomatitis;  the  latter  offers  a  good  soil 
for  the  development  of  noma.  There  is  regularly  present  in  noma 
a  streptothrix  characterized  by  a  thick  meshwork  of  mycelium  at 
the  border  line  between  normal  and  necrotic  tissue;  fine  rods  and 
spirilla  extend  from  mycelium  into  the  adjacent  tissues.  The 
constant  presence  of  this  streptothrix,  to  the  exclusion  of  other 
organisms,  indicates  that,  in  all  probability,  it  stands  in  direct 
etiological  relationship  to  noma.  The  streptothrix  is  present  in 
noma  before  the  disease  is  fully  manifest — in  the  pregangrenous 
stage.  It  is  in  this  stage  of  the  disease  that  radical  treatment  is  to 
be  practised;  after  the  ulcer  spreads,  the  best  results  are  obtained 
by  conservative  measures.  General  anesthesia  should  not  be 
employed  in  any  form  of  treatment  because  of  the  pronounced 
tendency  to  the  development  of  septic  pulmonary  disease. 

28  Blood  examinations  were  made  in  four  cases.  There  was  a  marked  anemia  (2,000,000  red 
cells),  with  decided  poikilocytosis  and  anisocytosis ;  no  leukocytosis.  The  blood  drop  was  very 
watery  and  was  expressed  with  difficulty.  Cells  resembling  myelocytes  were  present  in  the 
spreads.  In  three  patients  Wassermann  tests  were  kindly  made  by  Dr.  Kaplan,  bacteriologist 
to  the  Montefiore  Home,  with  negative  results.  They  were  done  because  it  has  been  suggested 
that  the  organism  of  noma  is  in  the  same  class  as  Treponema  pallidum. 


714  WEIL:  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 


THE  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD  SERUM:  ITS 
SIGNIFICANCE  AND  ITS  DIAGNOSTIC  VALUE.1 

By  Richard  Weil,  M.D., 

OP  NEW  YORK. 

(From  the  Department  of  Experimental  Therapeutics,  of  Cornell  University  Medical  College.) 

It  is  not  much  more  than  a  year  ago  that  Brieger  and  Trebing 
announced  that  a  new  characteristic  of  the  blood  in  cases  of  cancer 
had  been  determinend.  This  new  feature  consisted  in  a  marked 
increase  in  the  power  of  the  serum  to  inhibit  the  proteolytic  activity 
of  solutions  of  trypsin,  and  was  so  constant  an  accompaniment  of 
cancer  as  to  be  present  in  over  95  per  cent,  of  the  cases.  Since  the 
publication  of  their  original  paper,  investigations  on  this  subject 
have  followed  each  other  in  rapid  succession,  so  that  the  literature 
has  come  to  assume  a  very  goodly  volume.  As  the  result  of  this 
accumulation  of  data,  it  has  become  increasingly  evident  that  the 
"antitryptic  reaction,"  as  it  is  called,  is  not  an  exclusive  charac- 
teristic of  cancer:  it  appears  under  certain  other  conditions  of 
disease;  it  marks  the  change  from  breast  to  artificial  feeding  in 
infants;  it  is  a  striking  feature  of  the  onset  of  labor  and  the  puer- 
perium,  as  contrasted  with  pregnancy;  in  other  words,  it  appears 
to  be  a  physiological  adaptation  of  widespread  significance  and 
value.  On  the  other  hand,  the  fact  is  not  to  be  gainsaid  that  the 
accumulation  of  evidence  has  not  materially  weakened  the  assump- 
tion originally  maintained  by  Brieger  and  Trebing — the  antitryptic 
reaction  is  an  almost  constant  accompaniment  of  cancer,  and  occurs 
in  a  very  much  smaller  proportion  of  all  other  diseases.  The  sig- 
nificance of  this  association  between  cancer  and  this  biological 
change  in  the  character  of  the  serum  must  be  regarded  as  a  matter 
of  some  importance,  aside  from  any  practical  diagnostic  application 
which  may  attach  to  it.  It  is  part  of  the  larger  problem  of  the 
general  constitutional  influence  exercised  by  the  newgroAvth  upon 
its  host.  In  a  larger  view,  the  physiological  value  of  the  reaction, 
and  its  general  relation  to  the  subject  of  immunity,  is  a  matter 
which  requires  elucidation.  In  the  present  paper  the  subject  will 
be  considered  from  the  various  points  of  view  which  have  occupied 
investigators,  and  which  have  been  outlined  above. 

Methods.2  The  methods  at  present  in  use  for  determining  the 
antitryptic  value  of  serum  are  the  fruit  of  a  long  process  of  evolution, 
the  details  of  which  need  not  here  be  sketched.  There  are  essentially 
two  methods  in  common  use.    The  first  of  these,  which  was  em- 

1  Referat  to  the  American  Association  for  Cancer  Research,  read  at  a  meeting  held  in  New 
York  City,  November  27,  1909. 

2  A  more  detailed  critique  of  these  methods  may  be  found  in  a  paper  by  the  author, 
Archives  of  Internal  Medicine,  1910,  p.  109. 


WEIL:  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD  715 

ployed  by  Brieger  and  Trebing,3  makes  use  of  plates  of  coagulated 
serum  as  the  medium  of  digestion;  on  such  plates  a  drop  of  solu- 
tion of  trypsin  within  twenty-four  hours  makes  a  visible  depression 
or  dell.  A  series  of  mixtures  of  the  serum  under  examination,  and 
of  a  standard  solution  of  trypsin,  is  prepared,  in  which  a  constant 
quantity  of  the  serum  is  added  to  increasing  amounts  of  the  ferment. 
Of  each  of  these  mixtures  a  loopful  is  transferred  to  the  surface  of 
the  plates,  which  are  then  incubated  at  55°  for  twenty-four  hours. 
In  this  manner  it  is  possible  to  determine  in  each  case  just  how 
much  of  the  trypsin  solution  can  be  totally  inhibited  by  the  standard 
quantity  of  serum,  and  so,  to  determine  the  "antitryptic  titer"  of  the 
serum.  The  other  method,  known  both  as  that  of  Fuld  and  of  Gross,4 
employs  a  solution  of  casein  as  the  medium  of  digestion.  The  serum 
in  constant,  and  the  trypsin  solution  in  ascending,  quantities,  are 
added  to  a  series  of  test-tubes  containing  equal  amounts  of  casein 
in  solution.  At  the  end  of  two  hours  of  incubation,  the  undigested 
casein  is  precipitated  in  all  of  the  tubes  by  acidification;  note  is 
made  of  the  lowest  amount  of  trypsin  which  produces  complete 
digestion,  and  this  is  taken  to  indicate  the  limit  of  the  inhibitive 
activity  of  the  serum.  The  results  in  both  methods  are  expressed 
in  figures,  which  denote  the  number  of  tenths  of  a  cubic  centimeter 
of  trypsin  inhibited.  Through  a  preliminary  determination  of  the 
inhibitory  limits  of  normal  serum  it  becomes  possible  to  determine 
that  certain  serums  have  greatly  diminished  or  greatly  increased 
inhibitory  power. 

As  regards  the  purely  technical  details  of  these  methods,  it  may 
be  said  that  both  of  them  suffer  from  rather  serious  defects.  The 
serum-plate  method  is  open  to  the  same  objection  which  has  been 
made  to  Mette's  method  of  measuring  the  peptic  activity  of  the 
gastric  juice  by  means  of  the  quantitative  measurement  of  the 
amount  of  egg  albumen  which  it  is  capable  of  digesting.  Both 
egg  albumens  and  the  coagulated  serums  of  different  animals  differ 
very  considerably  among  themselves  in  digestibility,  so  that  there 
is  not  the  required  constant  basis  of  comparison  (Klineberger 
and  Scholz5).  Furthermore,  the  visual  appreciation  of  a  minute 
depression  on  the  surface  of  a  serum  plate  is  a  very  difficult  and 
inexact  procedure.  When  to  these  sources  of  error  is  added  the 
fact  that  incubation  is  necessarily  carried  out  at  55° — certainly  far 
from  the  optimum  for  trypsin — and  that  bacterial  contamination  is 
a  possible,  though  not  a  frequent,  element  of  confusion,  it  may  be 
understood  that  the  method  yields  results  only  approximately  accu- 
rate. The  casein  method  is  certainly  far  simpler  and  easier  to 
manipulate.  In  addition  to  this,  it  has  the  added  advantages  of 
greater  accuracy  in  the  mixture  of  reagents,  a  normal  temperature  of 
incubation,  and  a  period  of  experiment  so  short  as  to  exclude  bac- 


3  Berl.  klin.  Woch.,  1908,  p.  1041. 

6  Deut.  Archiv  f.  klin.  Med.,  1908,  p.  319. 


4  Archiv  f.  exp.  Path.,  1907,  p.  137. 


716 


WEIL:  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 


terial  contamination;  furthermore,  the  " end-points"  of  the  readings 
are  fairly  sharp  and  accurate.  Brieger6  has  objected,  with  regard 
to  this  method,  that  the  classification  of  serums  is  more  or  less  inexact; 
that  the  results  are  inconstant;  and  that  the  acid  may  produce  a 
soluble  acid  albumin,  and  so  obscure  the  "end-point"  of  the  series 
of  readings.  None  of  these  objections,  however,  is  valid  in  fact; 
they  are  all  purely  theoretical.  Numerous  other  objections  have 
been  made  to  the  methods,  the  most  important  being  that  recently 
advanced  by  Marcus,7  who  was  one  of  its  originators.  He  states, 
as  is  well  known  to  be  the  fact,  that  only  a  portion  of  the  trypsin  goes 
into  solution,  and  hence  maintains  that  there  must  be  a  considerable 
degree  of  variation  in  the  strength  of  solutions  presumed  to  be 
equal.  He  proposes  to  obviate  this  very  serious  difficulty  by  means 
of  the  use  of  glycerin  extracts  of  the  trypsin,  which  preserve  their 
strength  unaltered  for  considerable  periods  of  time,  and  hence  may 
be  kept  as  standard  stock  solutions.  Although  apparently  valid, 
this  objection  does  not  withstand  the  test  of  experiment.  As  shown 
by  Dr.  Feldstein  and  myself,  the  strength  of  a  series  of  solutions  of 
trypsin,  made  up  independently  with  equal  amounts  of  the  ferment 
and  salt  solution,  is  astonishingly  constant,  and  there  is  no  need  of 
the  modification  suggested  by  Marcus.  The  insoluble  material  is 
apparently  evenly  distributed  as  an  inert  impurity  in  the  commercial 
trypsins. 

The  most  serious  objection  which  can  be  made  to  the  method 
concerns  the  notation  of  results.  This  is  apparently  very  simple. 
The  results  are  stated  in  units,  which  represent  the  amounts  of 
trypsin  inhibited,  in  tenths  of  a  cubic  centimeter  of  the  standard 
solution  used.  This  mode  of  representing  the  results  depends  on 
the  assumption  that  the  amount  of  antitrypsin  contained  by  serums 
is  directly  proportional  to  the  quantity  of  trypsin  which  they  are 
capable  of  inhibiting.  In  other  words,  the  method  presupposes  that 
a  serum  of  the  titer  0.6  is  twice  as  strong  as  one  of  0.3.  Neither  the 
method  of  Brieger  nor  of  Bergmann  permits  of  an  experimental  tests 
of  this  hypothesis,  but  determinations  made  with  the  viscosimeter 
demonstrate  that  these  relationships  are  distinctly  not  so  simple  as 
demanded  by  the  theory.  If  an  arithmetical  series  of  solutions  of 
trypsin  be  prepared,  and  the  necessary  inhibitory  amount  of  serum 
determined  for  each  member  of  the  series,  it  is  found  that  the  quanti- 
tative intervals  in  the  higher  determination  become  increasingly 
larger.  Consequently,  the  proportion  indicated  by  the  figures 
obtained  by  the  serum  or  casein  methods  is  entirely  incorrect. 
Nevertheless,  the  relative  antitryptic  strength  of  the  serums  is  correct, 
at  least  from  a  quantitative  standpoint,  and  it  is  fair  to  accept  the 
grouping  of  serums  obtained  by  these  methods  as  approximately 
accurate. 

6  Berl.  klin.  Woch.,  1908,  1415,  in  report  of  discussion, 
^  Ibid.,  1909,  p.  156. 


WEIL:  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 


717 


The  viscosity  method8  previously  referred  to  depends  on  the  fact 
that  the  amount  of  digestion  produced  by  trypsin  in  gelatin  may  be 
measured  by  determining  the  alteration  in  the  viscosity  of  the  latter 
medium.  The  effect  of  serum  in  controlling  the  activity  of  the 
trypsin  is,  of  coure,  very  simply  determined.  The  method  offers 
certain  very  distinct  advantages  over  those  previously  employed. 
Whereas,  by  the  serum  or  casein  methods,  it  is  possible  to  make  only 
one  determination,  namely,  either  the  point  of  complete  inhibition 
or  of  total  digestion,  the  viscosimeter  determines  the  degree  of  inhi- 
bition at  any  moment  of  time.  The  method,  therefore,  substitutes 
the  use  of  a  single  mixture  for  that  of  a  series,  which  is  a  very  con- 
siderable gain  in  simplicity  of  technique.  Moreover,  the  method  is 
incomparably  more  flexible  than  those  previously  used,  and  permits 
of  the  determination  of  a  large  number  of  factors  otherwise  inacces- 
sible to  investigation. 

The  results  obtained  by  the  use  of  the  two  earlier  methods  have 
been  strikingly  concordant.  Indeed,  in  comparing  the  findings  yielded 
in  a  series  of  cases  by  both  the  serum  and  the  casein  methods,  I  found 
that  the  data  were  practically  interchangeable.  Brieger  originally 
asserted  that  about  95  per  cent,  of  the  cases  of  cancer  evinced  a 
marked  increase  in  the  antitryptic  value  of  their  serum.9  He  subse- 
quently found  that  in  a  large  number  of  other  conditions,  including 
both  acute  infections  and  chronic  wasting  diseases,  the  same  phe- 
nomenon could  be  observed,  and  he  consequently  concluded  that  all 
diseases  associated  with  intense  destruction  of  body  protein  produced 
this  characteristic  alteration  in  the  plasma  of  the  blood.  Hence, 
although  he  continued  to  affirm  the  diagnostic  value  of  the  method 
in  all  cases  of  undetermined  newgrowth,  he  reached  the  conclusion 
that  in  general  all  conditions  of  "  cachexia" — using  that  term  in  the 
broad  metabolic  sense  of  wasting  disease,  either  acute  or  chronic — 
were  competent  to  produce  it.  Further  investigation  has,  in  general, 
given  ample  confirmation  to  these  conclusions,  if  the  term  cachexia 
is  interpreted  in  the  peculiar  sense  in  which  it  was  used  by  Brieger. 
All  observers  are  agreed  that  the  great  majority  of  cases  of  cancer 
give  evidence  of  increased  antitryptic  value  in  the  serum.  In  some 
series  the  percentage  of  positive  results  in  cases  of  cancer  ranges  as 
high  as  95  per  cent. ;  in  others  as  low  as  70  per  cent.  It  is,  however, 
very  frequently  found  in  the  acute  infections,  such  as  pneumonia, 
typhoid  fever,  sepsis,  and  polyarticular  rheumatism;  in  chronic  infec- 
tions, notably  tuberculosis;  in  diabetes  and  severe  anemias;  and  in 
Graves'  disease  almost  constantly.  These  data  amply  demonstrate 
that  the  change  in  the  serum  is  not  to  be  regarded  as  a  characteristic 
biological  response  to  the  presence  of  newgrowth s.  They  indicate 
that  it  is  an  evidence  of  pathological  derangement  of  much  wider 

8  Since  the  presentation  of  this  paper,  a  preliminary  report  on  the  viscosity  method  has 
appeared,  Feldstein  and  Weil,  Proc.  Soc.  Exp.  Biol,  and  Medicine,  February,  1910. 

9  Bed.  klin.  Woch.,  1908,  pp.  1349  and  2260. 

vol.  139,  no.  5— may,  1910.  24 


718  WEIL!  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 


distribution.  Furthermore,  it  seems  misleading  to  consider  the 
reaction  as  characteristic  of  conditions  of  cachexia,  in  view  of  the 
fact  that  this  term  must  be  extended  so  as  to  include  a  large  number 
of  conditions  which  can  by  no  possibility  be  classified  as  cachectic. 
The  general  condition  of  nutrition  of  patients  whose  serum  yields  the 
reaction  is  frequently  excellent,  and  could  never  be  understood  as 
cachectic.  The  theory  of  causation  involved  in  the  term  "Kachexie 
Reaktion"  will  be  subsequently  discussed,  but  the  term  itself  should 
certainly  be  allowed  to  fall  into  disuse 

Not  only  under  pathological  conditions,  however,  does  this  reac- 
tion occur.  It  has  been  found  to  accompany  and  characterize  cer- 
tain processes  which  may  be  called  physiological,  although  they 
denote  a  certain  alteration  in  the  normal  course  of  metabolism.  Its 
occurrence  in  the  blood  of  infants  has  been  investigated,  and  it  has 
been  found  that  such  infants  as  are  being  nourished  at  the  breast 
never  display  an  increased  antitryptic  content  of  the  blood  (Reuss10). 
On  the  other  hand,  with  the  inauguration  of  artificial  feeding,  the 
reaction  at  once  becomes  prominent.  In  pregnancy  it  has  been 
found  that  no  antitryptic  reaction  occurs,  but  with  the  onset  of 
labor  it  makes  its  appearance,  and  persists  through  the  puerperium 
(Becker11). 

It  is  evident  that  these  findings  may  be  discussed  either  from  the 
standpoint  of  their  diagnostic  value,  or  as  a  biological  phenomenon 
of  purely  theoretical  interest.  Diagnostically,  the  opinion  of  the 
various  authors  who  have  worked  upon  this  problem  is  strikingly 
in  accord.  As  a  general  diagnostic  method,  the  increase  in  the 
antitryptic  index  occurs  in  too  many  conditions  to  have  the  value 
of  a  specific  symptom.  On  the  other  hand,  the  absence  of  the  anti- 
tryptic reaction  in  the  blood  may  be  taken  generally  as  arguing 
against  the  existence  of  cancer.  In  the  presence  of  a  neoplasm  of 
doubtful  character,  a  positive  reaction,  in  the  absence  of  complicating 
conditions,  notably  tuberculosis,  argues  with  a  strong  degree  of 
probability  in  favor  of  the  diagnosis  of  malignancy  (Roche,12  Hort,13 
Braunstein,14  Bayly15). 

The  method  has  apparently  stood  the  test  of  clinical  experience, 
and  has  proved  to  be  of  distinct  value  when  applied  rigidly  within 
the  prescribed  limits.  As  regards  other  conditions,  Meyer16  asserts 
that  the  reaction  occurs  with  such  regularity  in  cases  of  Graves' 
disease,  that  it  may  be  relied  upon  in  the  diagnosis  of  the  numerous 
obscure  and  abortive  forms  of  the  disease  known  as  formes  frustes. 
It  has  been  claimed  by  Wiens17  that  the  strength  of  the  reaction  has 

i°  Wiener  klin.  Woch.,  1909,  p.  1171.  11  Munch,  med.  Woch.,  1909,  p.  1363. 

i2  Archives  of  Internal  Medicine,  1909,  p.  249.  13  Brit.  Med.  Jour.,  1909,  p.  966. 

14  Deut.  med.  Woch.,  1909,  p.  573. 

15  Brit.  Med.  Jour.,  1909,  p.  1220.    (Bayly  measured  digestion  by  electroconductivity.) 
16Berl.  klin.  Woch.,  1909,  p.  1064. 

17  Deut.  Archiv  f.  klin.  Med.,  1909,  p.  62. 


WEIL:  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD  719 


marked  prognostic  value  in  the  acute  infections,  but  this  view  is 
certainly  erroneous. 

Looked  at  as  a  biological  phenomenon,  the  reaction  suggests 
many  problems,  and  has  given  rise  to  a  considerable  amount  of 
research.  The  chemical  nature  of  the  antitrypsin,  its  character  as  a 
specific  "immune  body,"  its  relationship  to  artificially  produced 
antitrypsin,  and  the  causes  of  its  production,  are  subjects  which 
demand  elucidation,  if  the  physiological  significance  and  the  patho- 
logical import  of  the  reaction  are  to  find  an  explanation. 

The  chemical  basis  of  the  antitryptic  reaction  has  not  been  satis- 
factorily determined.  It  was  originally  asserted  by  Glaessner18  that 
the  antitrypsin  was  associated  with  the  euglobulin  fraction  of  the 
serum,  which  is  that  part  of  the  serum  globulins  least  soluble  in 
water,  and  roughly  corresponds  to  the  fraction  which  comes  down 
in  dialyzing  or  on  adding  acetic  acid  to  the  diluted  serum  (Hedin19). 
Cathcart,20  on  the  other  hand,  asserts  that  the  globulins  do  not  pos- 
sess antitryptic  action,  but  that  this  is  characteristic  of  the  albumin 
fraction,  that  is,  the  fraction  precipitated  between  half  and  full 
saturation  with  ammonium  sulphate.  Schwarz21  has  reached  the 
conclusion  that  the  antitryptic  fraction  of  the  serum  exists  in  the 
form  of  a  lipoid.  He  found  that  he  could  inactivate  antitryptic 
serums  by  washing  out  the  lipoids  with  ether.  Such  serums  could  be 
reactivated  by  the  addition  of  lecithin.  Lecithin  in  salt  solution 
emulsion,  if  added  to  serum,  exercised  considerable  tryptic  inhibition ; 
if  the  mixtures  were  kept  at  65°  for  one  hour,  this  inhibitory  activity 
was  markedly  enhanced,  indicating  that  the  inhibitory  substance  is 
a  lipoid-albumin  compound.  (  Furthermore,  he  found  by  analysis 
that  increase  in  the  antitryptic  titer  of  a  serum  was  constantly  asso- 
ciated with  an  increase  in  the  amount  of  ether-soluble  substances 
which  it  contained.  These  conclusions  substantiate  the  earlier 
findings  of  Pribram.  Interesting  as  are  these  data,  they  fail  to  sup- 
port the  contention  that  antitrypsin  is  a  lipoid  substance.  It  is  well 
known,  for  example,  that  lipoids  are  essential  to  the  activation 
of  cobra  venom  in  the  production  of  hemolysis;  nevertheless,  it 
would  be  erroneous  to  consider  the  lipoid  substance  as  the  active 
hemolysin.  Lipoids  have  been  shown  (Bang22)  to  play  an  analogous 
auxiliary  role  in  many  processes  of  immunity,  while  the  essential 
factor,  the  active  agent,  is  a  protein.  It  is  conservative  to  maintain 
this  position  with  reference  to  antitrypsin,  admitting  meanwhile  the 
possible  importance  of  lipoids  as  subsidiary  factors. 

Is  the  so-called  antitryptic  action  of  the  serum  dependent  on  the 
presence  of  an  "immune  body,"  or  is  it  an  accidental  property  of 
the  serum?  This  question  is  really  of  fundamental  importance, 
though  not  at  all  easy  to  answer.    It  was  found  by  Vernon23  that 


18  Hofmeister's  Beitriige,  190.3,  iv,  79. 

20  Ibid.,  1904,  xxxi,  496. 

-2  Ergebnisse  d.  Physiologie,  1909,  p.  403. 


111  Jour.  Physiol.,  1903,  p.  193. 

21  Wien.  klin.  Wooh.,  1909,  p.  1151 

"Jour.  Physiol.,  1904,  p.  346. 


720  WEIL :  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 

egg  albumin  in  solution  inhibits  the  digestive  action  of  trypsin  very 
actively.  But  it  is  a  still  more  striking  fact  that  charcoal  has  been 
shown  to  act  as  an  antitryptic  agent,  in  a  manner  very  similar  to 
serum.  The  amount  of  inhibition  is  proportional  to  the  quantity  of 
charcoal,  to  the  time  of  interaction,  and  to  the  temperature,  just  as  it 
is  in  the  case  of  serum.  In  fact,  "the  action  of  charcoal  was  found 
to  agree  with  that  of  the  tryptic  antibody  in  all  respects  tried,  and 
therefore  the  neutralizing  effect,  in  all  probability >  is  brought  about 
in  the  same  way  in  both  cases"  (Hedin24).  It  is  perfectly  apparent 
that  neither  egg  albumen  nor  charcoal  can  in  reality  contain  a  true 
antitrypsin,  and  that,  therefore,  the  effect  observed  is  simply  an  acci- 
dental phenomenon.  It  is  true  of  all  human  serums  that  they  very 
notably  inhibit  the  hemolytic  effect  of  saponin;  it  would,  however, 
be  entirely  unjustifiable  to  argue  from  this  fact  to  the  existence  of 
an  "antisaponin."  These  theoretical  objections  to  the  assumption 
of  an  "antitrypsin"  in  the  serum  have,  unfortunately,  not  received 
recognition  in  the  recent  literature.  On  the  other  hand,  it  must  be 
admitted  that  certain  observations  argue  strongly  in  favor  of  a  true 
antitrypsin,  as  against  a  general  property  of  serum  albumin,  in  the 
interpretation  of  tryptic  inhibition.  Chief  among  these  is  the 
alleged  specificity  of  the  antitryptic  action.  Specificity  is,  as  is  well 
understood,  one  of  the  most  striking  characteristics  of  all  forms  of 
antibody,  and  its  absence  may  well  be  interpreted  as  a  powerful 
argument  in  the  negative.  Eisner,-5  as  the  result  of  a  series  of  tests 
made  with  the  same  serums  against  rennet,  pepsin,  emulsin,  and 
cobra  lipase,  arrived  at  the  conclusion  that  serum  does  not  exhibit 
the  properties  of  a  general  ferment  inhibitor,  but  that  it  possesses 
a  special  and  characteristic  affinity  for  trypsin.  This  observation 
seems  to  indicate  the  existence  of  a  specific  antibody,  a  true  anti- 
trypsin. Glaessner  has  also,  on  insufficient  evidence  (Cathcart), 
asserted  that  the  antitrypsin  of  serum  is  most  active  against  the 
trypsin  of  the  same  species,  and  is  somewhat  specific  even  for 
various  animal  trypsins.  The  facts  do  not,  however,  appear  to  bear 
out  these  contentions.  It  has  been  possible  in  our  laboratory,  by 
means  of  the  viscosimeter,  to  demonstrate  that  all  human  serums 
inhibit  papain,  which  is  a  vegetable  proteolytic  ferment,  in  a  con- 
stant ratio  to  the  degree  with  which  they  inhibit  trypsin.  It  seems, 
therefore,  impossible  to  accept  the  specificity  of  the  antitrypsin  of 
the  serum.  The  antitryptic  function  is  exercised  by  an  albuminous 
substance,  thermolabile,  indeed,  like  the  true  antibodies,  but  dif- 
fering essentially  from  these  in  the  lack  of  specificity.  In  view  of 
this  fact,  and  of  certain  other  differences,  the  argument  (Meyer26) 
in  favor  of  a  true  antibody  as  the  basis  of  this  function  of  the  serum 
loses  very  materially  in  credibility. 

24  Biochemical  Journal,  1906,  p.  484. 

25  Ztschr.  f.  Immunitatsforschung,  1909,  ii,  650. 
2e  Berl.  klin.  Woch.,  1909,  p.  2139. 


WEIL :  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD  721 


This  conclusion  makes  it  very  much  simpler  to  dispose  of  the 
much  debated  problem  as  to  the  identity  of  the  normal  antitrypsin 
of  the  serum  with  that  produced  artificially  in  animals  by  the  injec- 
tion of  trypsin.  All  antiferments  hitherto  produced  by  this  method 
have  been  found  to  be  characteristically  specific.  Thus,  by  the 
injection  of  rennet,  Morgenroth27  succeeded  in  producing  an  anti- 
rennin  which  powerfully  inhibited  the  action  of  the  injected  ferment, 
but  had  no  influence  on  vegetable  rennet.  The  entire  subject  of 
antiferments  is,  however,  in  such  a  condition  of  confusion  that  it  is 
almost  impossible  to  draw  any  very  definite  conclusions.  Achalme28 
produced  an  active  antitrypsin  by  the  injection  of  trypsin,  but 
Landsteiner  failed  to  reproduce  this  result.  In  our  own  laboratory, 
the  injection  of  trypsin  into  guinea-pigs  has  been  uniformly  without 
effect.  The  most  striking  experiments  are  those  recently  reported 
from  the  Pasteur  Institute  on  the  result  of  the  injection  of  pepsin 
and  of  papain.  It  has  been  shown  by  Cantacuzene  and  Jonescu29 
that  when  rabbits  are  immunized  to  pepsin  by  the  injection  of 
increasing  doses,  the  serum  responds  by  the  production  of  an  anti- 
body capable  of  fixing  complement,  but  possesses  no  increased 
antiferment  action.  Similarly,  Pozerski30  has  shown  that  the  serum 
of  animals  immunized  to  papain  contains  a  specific  precipitin,  and  an 
antibody  which  fixes  complement  in  a  characteristic  fashion;  but 
this  very  immunized  serum  is  just  as  easily  digested  by  the  ferment 
as  is  normal  serum.  The  natural  antitrypsin,  so-called,  differs, 
therefore,  in  many  important  particulars  from  the  antibody  arti- 
ficially produced  by  the  injection  of  ferments  into  animals,  and  this 
fact  constitutes  an  additional  argument  for  regarding  it  as  some- 
thing essentially  different  from  a  true  antibody. 

The  conception  of  antitrypsin  as  an  antibody  has,  however,  domi- 
nated practically  all  the  theories  which  have  hitherto  been  advanced 
in  the  attempt  to  explain  it.  In  spite  of  the  fact  that  it  cannot 
properly  be  so  regarded,  these  theories  do  not  necessarily  forfeit 
their  validity.  It  is  perfectly  reasonable  to  assume  that  the  serum 
may  respond  to  a  given  stimulus  by  means  of  a  protective  mechanism 
which  does  not  answer  to  the  criteria  characteristic  of  antibodies 
and  amboceptors.  It  has  generally,  and  very  naturally,  been 
assumed  that  the  presence  of  antitrypsin  in  the  serum  is  evidence  of 
an  effort  on  the  part  of  the  organism  to  protect  itself  against  self- 
digestion.  If  this  be  the  case,  then  a  tryptic  ferment  should,  theo- 
retically, be  present  in  the  serum,  and  this  has  actually  been 
demonstrated  to  be  the  fact  by  Hedin  and  by  Delezenne;31  it  is, 
therefore,  an  important  matter  to  determine  its  source  of  supply. 

27  Centralbl.  f.  Bakteriologie,  1899,  p.  349. 
28Annales  de  l'lnstitut  Pasteur,  1901,  xv,  736. 
29  Compt.-rend.,  de  la  Soc.  de  Biol.  1909,  p.  53. 
3°  Annales  de  l'lnstitut  Pasteur,  1909,  p.  205. 
3i  Compt.-rend.  de  la  Soc.  de  Biol.,  1903,  lv,  132. 


722 


WEIL:  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 


There  are  four  of  such  sources  theoretically  conceivable  at  present, 
namely,  the  pancreas,  the  leukocytes,  the  organs,  and  the  new- 
growths.  Each  of  these  has  had,  and  has,  its  champions,  and 
each  requires  consideration.  The  pancreas,  as  a  source  of  supply 
of  trypsin,  is  a  very  obvious  suggestion.  Ambard32  suggests  that 
the  antitryptic  reaction  is  so  marked  in  cases  of  gastric  carcinoma, 
because  this  condition  is  associated  with  compensatory  overactivity 
of  the  pancreas.  There  is,  however,  no  evidence  that  the  pan- 
creatic trypsin  is  absorbed  from  the  intestine,  and  circulates  in 
the  serum.  Moreover,  the  explanation  fails  to  explain  the  increase 
in  Graves'  disease,  or  the  acute  infections.  The  polynuclear 
leukocytes,  as  is  well  known,  contain  an  active  proteolytic  fer- 
ment in  most  respects  identical  with  trypsin.  It  has  been  urged 
that  the  constant  disintegration  of  leukocytes  must  necessarily  free 
a  considerable  amount  of  this  ferment  in  the  serum,  and  Hedin 
is  of  the  opinion  that  the  tryptic  ferment  which  he  succeeded 
in  isolating  from  the  serum  actually  represents  the  remnant  of  the 
intraleukocytic  ferment.  The  view  that  the  antitryptic  reaction 
of  serum  is  the  manifestation  of  a  response  to  the  excessive  disinte- 
gration of  leukocytes  has  been  urged  and  defended  by  Jochmann,33 
Wiens,34  Weins  and  Schlecht,35  Bittorf,36  Landois,37  and  many  others. 
As  a  result  of  the  study  of  a  large  number  of  pathological  conditions 
in  which  the  differential  leukocyte  curve  has  been  carefully  plotted, 
and  the  antitryptic  strength  of  the  serum  also  has  been  repeatedly 
determined,  it  appears  that  there  are  certain  definite  relationships 
between  these  two  factors.  It  has  been  quite  satisfactorily  demon- 
strated that  with  the  onset  of  an  infection  the  antitryptic  index  of 
the  serum  falls,  and  that  with  the  progress  of  the  infection  it  gradually 
rises  again  to  the  level  of  the  normal,  and  then  passes  well  beyond 
this  to  a  highly  increased  index  (Landois).  Wiens,  and  Wiens  and 
Schlecht,  have  shown  that  these  fluctuations  in  the  antitryptic  index 
are  accurately  foreshadowed  by  variations  in  the  leukocyte  count, 
but  only  in  so  far  as  the  polynuclear  leukocytes  determine  these 
variations.  The  mononuclear  cells  do  not  play  any  role  in  influ- 
encing the  index,  and  it  is,  therefore,  of  importance  in  the  under- 
standing of  the  interrelationship  of  these  phenomena  that  the  differ- 
ential count  should  invariably  be  made.  The  explanation  of  these 
relationships  is  based  on  the  well-known  fact  of  the  trypsin  content 
of  the  polynuclear  cells.  With  the  onset  of  acute  infections  there 
is  an  immediate  and  rapid  increase  in  the  number  of  circulating 
polynuclear  leukocytes.    The  inevitable  destruction  of  a  certain 

32  Sem.  med.,  1908,  p.  .532. 

33  Miinch.  med.  Woch.,  1908,  lv,  728;  Hofmeister's  Beitrage,  1908,  p.  449. 

34  Deut.  Arch.  f.  klin.  Med.,  1907,  p.  456;  Miinch.  med.  Woch.,  1907,  p.  2637;  Centralbl. 
f.  Inn.  Med.,  1908,  p.  773. 

35  Deut,  Archiv  f.  klin.  Med.,  1909,  p.  44.  3fi  Ibid.,  1907,  xci,  p.  212. 
3?Berl.  klin.  Woch.,  1909,  p.  440. 


WEIL:  ANTITRYPT1C  ACTIVITY  OF  HUMAN  BLOOD 


723 


proportion  of  these  cells  frees  an  excessive  amount  of  trypsin, 
which  at  once  neutralizes  all  the  available  antitrypsin  in  the  serum. 
Consequently,  the  antitryptic  index  falls  well  below  normal,  and 
may  even  disappear.  This  is  the  so-called  negative  phase  of  the 
antitryptic  curve.  The  excess  of  trypsin  in  the  blood,  however, 
stimulates  the  production,  or  the  mobilization,  of  fresh  quantities 
of  antitrypsin,  which,  in  accordance  with  Ehrlich's  interpretation  of 
Weigert's  laws  of  regeneration,  are  well  in  excess  of  the  amount  of 
trypsin  to  be  neutralized.  Consequently,  there  is  a  rapid  rise  in 
the  antitryptic  index.  This  is  the  so-called  positive  phase  of  the 
curve.  A  regulating  mechanism  of  some  kind  tends,  however,  to  keep 
the  amount  of  antitrypsin  in  circulation  only  a  little  in  excess  of  the 
trypsin,  and  this  gives  the  value  of  the  normal  index.  Fluctuations 
of  this  character,  in  which  the  leukocyte  count  and  the  curve  of  the 
antitryptic  index  pursue  a  parallel  course,  constitute  a  very  striking 
feature  of  all  infectious  conditions.  Wiens  went  so  far  as  to  assert 
that  in  such  conditions  a  constantly  increased  antitryptic  index  was 
an  omen  of  ill  import,  and  augured  the  paralysis  of  the  mechanism 
of  defence,  specifically  the  polynuclear  leukocytes.  Thaller38 
reached  similar  conclusions  with  reference  to  puerperal  sepsis.  In 
this  belief  they  were  unquestionably  in  error,  inasmuch  as  the  index- 
is  dependent  quite  as  much  on  the  amount  of  antitrypsin  liberated 
by  the  body  as  on  the  leukocytes  which  represent  the  reaction  to 
the  disease.  Indeed,  the  majority  of  acute  infections,  whether  the 
body  is  in  the  ascendant  or  not,  are  associated  with  an  increase  in 
the  antitryptic  index.  In  addition  to  these  clinical  observations, 
there  is  ample  experimental  evidence  (Miller39)  that  the  injection  of 
leukocytes,  or  of  leukocyte  extracts,  into  animals  is  followed,  after 
a  preliminary  fall,  by  a  marked  rise  in  the  antitryptic  index.  It 
may  be  seen  from  the  preceding  analysis  that  cases  of  myelogenous 
leukemia  would  not  necessarily  be  associated  with  any  notable 
variation  in  the  antitryptic  index,  inasmuch  as  the  regulatory 
mechanism  maintains  the  index  at  its  constant  normal  level.  Joch- 
mann,  however,  asserts  that  sudden  myelocyte  crises  may  so  flood 
the  blood  with  trypsin  that  the  serum  actually  assumes  digestive 
power,  in  place  of  its  normal  inhibitory  function. 

The  preceding  theory,  interesting  as  it  is,  does  not  fully  explain 
the  phenomena.  There  are  many  conditions,  such  as  diabetes, 
Graves'  disease,  and  so  forth,  in  which  there  is  no  increased  pro- 
duction of  leukocytes,  yet  the  antitryptic  index  is  constantly  increased. 
If  the  leukocyte  curve  be  admitted  to  afford  a  satisfactory  expla- 
nation of  the  index  in  infectious  conditions,  there  still  remains  a 
considerable  number  of  conditions  in  which  some  other  explanation 
must  be  discovered.  In  addition  to  the  pancreas  and  the  poly- 
nuclear leukocytes,  there  is  another  possible  source  of  trypsin  in  the 


:i»Berl.  klin.  Woch.,  1909,  p.  850. 


39  Zntralbl.  f.  Chir.,  1909,  p.  75. 


724 


WEIL :  ANTITRYPTIC  ACTIVITY  OF  HUMAN  BLOOD 


body,  namely,  the  cells  of  the  tissues.  It  has  now  been  abundantly 
shown  that  many,  if  not  all,  of  the  tissues  contain  proteolytic  fer- 
ments, which  are  competent  to  break  up  these  tissues  outside  of  the 
body  into  a  much  simpler  group  of  compounds.  This  process  is 
known  as  autolysis,  and  the  ferments  in  question  are  called  autolytic 
ferments.  Although  they  are  actively  proteolytic,  they  appear 
to  differ  in  certain  particulars  from  true  trypsin.  Thus,  the  end- 
products  indicate  that  an  ereptic  ferment  is  almost  certainly  at 
work  (Vernon40).  Furthermore,  it  has  been  asserted  by  Jacoby41 
that  these  ferments  are  adapted  specifically  to  the  proteolysis  only 
of  the  organs  in  which  they  occur,  a  characteristic  which,  if  well 
founded  (Beebe),42  would  sharply  differentiate  them  from  true  tryp- 
sin. In  spite  of  these  objections,  there  are  certain  facts  which 
indicate  their  possible  relationship  with  the  antitryptic  phenomenon 
of  the  serum.  In  the  first  place,  it  is  known  that  the  injection  of 
tissue  other  than  the  pancreas  may  induce  a  rise  in  the  antitryptic 
index.  Further,  serum  exercises  an  anti-autolytic  (Baer  and  Loeb43), 
just  as  it  does  an  antitryptic,  power.  Finally,  it  has  been  shown  by 
Shaffer  and  Buxton,44  and  others,  that  glycerin  extracts  of  the  various 
organs,  including  the  muscles,  are  capable  of  displaying  marked 
proteolytic  powers,  when  tested,  for  example,  upon  milk  agar  plates. 
The  difficulty  in  all  observations  of  this  kind  consists  in  excluding 
the  leukocytes  themselves.  If  it  must  be  admitted  that  the  condi- 
tions of  experimentation  have  not  yet  permitted  a  final  decision  as 
to  the  character  of  the  ferments  contained  in  the  organs,  the  fact 
still  remains  that  the  tissues  do  contain  a  proteolytic  ferment,  prob- 
ably very  similar  to  trypsin.  In  view  of  this  fact,  the  theory  has 
been  advanced  that  the  destruction  of  body  protein  from  any  cause 
would  tend  to  free  the  proteolytic  ferments  contained  in  the  cells, 
and  that  the  somatic  reaction  would  liberate  an  excess  of  antitrypsin 
in  the  serum.  This  theory,  it  will  be  seen,  is  simply  an  expansion  of 
the  leukocyte  theory,  inasmuch  as  the  leukocytes  may  be  considered 
as  a  type  of  cell  distinguished  by  their  increased  content  of  proteo- 
lytic ferments.  There  can,  indeed,  be  no  question  that  it  offers  an 
explanation  for  the  increased  index  in  a  large  number  of  diseases 
for  which  the  leukocyte  theory  is  entirely  inadequate,  such  as  the 
marasmus  of  infants  (Lust45).  This  includes  not  only  conditions 
such  as  Graves'  disease,  diabetes,  and  chronic  tuberculosis,  but  cer- 
tain acute  infections,  such  as  typhoid  fever,  not  associated  with 
leukocytosis.  There  is,  however,  one  very  weak  point  in  this  theory, 
in  spite  of  the  fact  that  it  apparently  harmonizes  with  clinical  con- 
ditions, and  this  is  the  unwarranted  assumption  that  heightened 
protein  metabolism  is  necessarily  associated  with  the  liberation 

40  Intracellular  Enzymes,  1909.  41  Ztschr.  f.  Physiol.  Chem.,  1901,  vol.  xxxiii. 

42  Boston  Med.  and  Surg.  Jour.,  1907. 

43  Arch.  f.  exp.  Path.,  1905,  p.  1;  1906,  p.  68. 

44  Jour.  Med.  Research,  1905.  45  Deut.  med.  Woch.,  1909,  p.  1901. 


fox:  wassermann  and  noguchi  fixation  test  725 

of  intracellular  ferments.  The  advocates  of  the  theory  have  de- 
voted a  great  deal  of  effort  to  the  support  of  this  assumption.  It 
has  been  asserted  (Furst)  that  starvation,  with  its  accompanying 
cellular  destruction,  raises  the  index,  but  this  again  has  been  denied 
(Meyer).  The  effect  of  cellular  poisons,  such  as  pilocarpin,  phos- 
phorus, and  potassium  cyanide,  has  been  tested,  but  without  the 
expected  result  in  raising  the  index.  The  kidneys  have  been  tied 
off,  and  allowed  to  necrose  in  situ,  but  in  spite  of  the  presumptive 
absorption  of  the  cellular  constituents  including  ferments,  no  rise 
in  the  antitryptic  index  was  observed.  It  must  be  admitted,  there- 
fore, that  experimental  data  fail  to  give  any  support  to  this  theory. 

The  increase  of  the  index  in  cancer  is  attributed  to  the  same 
cause,  namely,  the  liberation  of  the  intracellular  ferments,  which 
are  well  known  to  be  very  active  in  cancerous  growths  (Bamberg46). 
With  the  frequent  tendency  to  necrosis  in  tumors,  even  if  only  in 
microscopic  areas,  there  would  seem  to  be  abundant  opportunity 
for  the  absorption  of  ferments.  But  here,  again,  the  absence  of 
evidence  that  such  a  process  actually  does  occur  is  a  fundamental 
flaw  in  the  theory. 

To  sum  up,  the  origin  of  the  hypothetical  trypsin  which  is  sup- 
posed to  act  as  a  stimulant  for  the  production  of  antitrypsin,  or, 
technically  speaking,  as  antigen,  is  as  yet  undetermined.  It  may, 
conceivably,  arise  in  the  pancreas,  or  in  the  leukocytes,  or  in  the 
tissue  cells,  or  in  the  newgrowths,  or  in  each  one  of  these,  under 
varying  circumstances,  but  actual  evidence  that  it  does  so  arise  is 
at  the  present  time  an  absolute  necessity  for  the  establishment  of 
the  theory.  The  very  first  essential  is  to  determine  whether  or  not 
the  trypsin,  or  proteolytic  ferment  of  the  blood  is  increased,  in 
accordance  with  the  assumption  of  the  hypothesis,  in  the  conditions 
which  give  rise  to  an  increase  in  the  antitryptic  index.  At  the 
present  time,  no  method  seems  to  be  available  for  this  purpose. 


THE  WASSERMANN  AND  NOGUCHI  COMPLEMENT-FIXATION 
TEST  IN  LEPROSY.1 

By  Howard  Fox,  M.D., 

OF   NEW  YORK. 

The  first  to  obtain  a  positive  Wassermann  reaction  in  a  case  of 
leprosy  was  Eitner2  in  1906.    A  similar  report  was  made  by  Weichsel- 

4«Berl.  klin.  Woch.,  1908,  pp.  1396  and  1673. 

1  Read  at  a  meeting  of  the  Medical  Society,  of  the  State  of  New  York,  January  24,  1910. 

2  Ueber  den  Nachweis  von  Antikorpern  im  Serum  eines  Leprakranken  mittels  Komple- 
mentablenkung,  Wien,  klin.  Woch.,  1906,  No.  15,  p.  1555. 


726        fox:  wassermann  and  noguchi  fixation  test 


mann  and  Meier3  nearly  two  years  later.  Since  then  it  has  been 
found  by  a  number  of  observers  that  leprosy  quite  frequently  gives 
a  positive  reaction.  In  testing  26  advanced  cases  of  the  disease, 
Slatineanu  and  Danielopolu4  found  20  strongly  positive,  4  moderately 
positive,  and  2  weakly  positive  reactions.  Jundell,  Almkvist,  and 
Sandman,5  in  a  series  of  26  cases  obtained  4  strong  and  4  moderately 
positive  reactions.  In  2  cases  the  result  was  unsatisfactory,  while 
in  the  remaining  16  cases  the  reaction  was  negative.  Of  the  positive 
cases,  5  were  of  the  tubercular  and  3  of  the  maculo-anesthetic  type. 
From  this  Sandman  concludes  that  the  occurrence  of  the  reaction 
does  not  depend  upon  the  type  of  the  disease,  whether  tubercular 
or  anesthetic.  Meier0  on  the  other  hand  in  a  series  of  28  cases, 
found  positive  reactions  only  in  the  tubercular  type  of  leprosy.  All 
of  the  anesthetic  cases  gave  negative  reactions.  The  number  of 
cases  of  each  type  was  unfortunately  not  stated.  Similar  results 
were  obtained  by  Bruck  and  Gessner7  who  found  positive  reactions 
in  5  out  of  7  tubercular  cases  and  negative  reactions  in  3  anesthetic 
cases.  Positive  reactions  have  also  been  obtained  by  Gaucher  and 
Abrami8  in  8  cases  and  by  Frugoni  and  Pisani9  in  9  out  of  11  cases  of 
leprosy,  the  type  of  the  disease,  however,  not  being  stated. 

Eitner10  was  also  the  first  to  obtain  complement-fixation  in  leprosy, 
using  an  extract  of  leprous  tissue  as  antigen.  Similar  results  were 
later  reported  by  Slatineanu  and  Danielopolu,11  Gaucher  and  Abrami 
Sugai,12  Pasini,13  and  by  Frugoni  and  Pisani.  It  was  also  found  by 
Slatineanu  and  Danielopolu14  that  complement  could  be  fixed  by 
leprous  serum  employing  tuberculin  as  antigen.  Complement- 
fixation  in  leprosy  was  also  obtained  by  Frugoni  and  Pisani  by  using 
tuberculin,  tubercle  bacilli,  and  extracts  of  sarcoma  and  carcinoma 
as  antigen. 

It  has  been  my  privilege  during  the  past  six  months  to  have  em- 

'■'  Wassermannsche  Reaktion  in  einem  Falle  von  Lepra,  Deut.  med.  Woch.,  1908,  No.  31,  p. 
1340. 

4  Reaction  de  fixation  avec  le  serum  et  le  liquide  cephalo-rachidien  des  malades  atteints 
de  lepre  en  presence  de  l'antigene  syphilitique.  Stances  et  mem.  d.  1.  Soc.  d.  biol.,  1908,  xi, 
p.  347. 

a  Wassermann's  Syphilisreakton  bei  Lepra,  Zntralbl.  f.  innere  Med.,  1908,  No.  48,  p.  1181. 

6  Zur  Technik  und  klinischen  Bedeutung  der  Wassermannschen  Reakton.,  Wien.  klin. 
Woch.,  1908,  No.  51,  p.  1765. 

7  Ueber  Serumuntersuchungen  bei  Lepra,  Berl,  klin.  Woch.,  1909,  No.  13,  p.  589. 
?  Le  sero-diagnostic  des  formes  atypiques  de  la  lepre,  1909,  viii,  p.  152. 

9  Vielfache  Bindingseigenenschaften  des  Komplements  einiger  Sera  (Leprakranken)  und 
Ihre  Bedeutung.  Berl.  klin.  Woch.,  1909,  No.  33,  p.  1530. 

10  Zur  Frage  der  Anwendung  der  Komplementbindungsreakton  auf  Lepra,  Wien.  klin. 
Woch.,  1908,  No.  20,  p.  729. 

11  Sur  la  presence  d'anticorps  specifiques  dans  le  s£rum  des  malades  atteinte  de  lepre,  Seances 
et  mem  d.  1.  Soc.  de  biol.,  1908,  xi,  p.  309. 

12  Zur  klinisch-diagnostischen  Verwertung  der  Komplementbindungs  methode  bei  Lepra. 
Archiv.  f.  Dermatol,  u.  Syph.,  1909,  p.  313. 

13  Sulla  reazione  della  deviazione  del  complemento  nella  lepra.  Reviewed  in  Giorn.  Ital. 
d.  Malatt.  Vener.  e.d.  pelle,  1909,  No.  111. 

14  Reaction  de  fixation  dans  la  lepre  en  employant  la  tuberculine  comme  antigene,  Seances 
et  mem.  d.  1.  Sec.  de  Biol.,  1908,  lxv,  p.  530. 


fox:  wassermann  and  noguchi  fixation  test 


727 


ployed  the  Wassermann  reaction  in  60  cases  of  leprosy.  Fifteen  of 
these  cases  were  seen  in  various  clinics  and  hospitals  in  New  York 
City.  The  remaining  forty-five  were  seen  during  a  recent  visit  to 
the  Leper  Home  in  Louisiana,  an  institution  under  the  direction 
of  Dr.  Isadore  Dyer  of  New  Orleans.  All  of  these  15  cases  with 
one  exception  were  tested  by  both  the  regular  Wassermann  and  the 
Noguchi  methods,  the  results  in  all  cases  being  identical.  The  cases 
in  Louisiana  were  tested  alone  by  the  more  convenient  method  of 
Noguchi,  owing  to  lack  of  time  at  my  disposal.  The  technique  used 
was  the  same  as  that  described  in  some  of  my  previous  communica- 
tions15 and  will  be  here  omitted  for  the  sake  of  brevity.  It  may, 
however  be  remarked  that  the  antigen  used  in  the  Wassermann  test 
was  an  alcoholic  extract  of  syphilitic  liver.  The  antigen  used  in  the 
Noguchi16  test  consisted  of  acetone  insoluble  lipoids.  The  patient's 
serum  in  the  Noguchi  method  was  used  in  active  condition.  All 
of  the  cases  examined  were  undoubted  lepers,  many  of  them  having 
been  under  observation  for  years.  No  history  of  syphilis  was  obtain- 
able in  any  case.  Certainly  no  lesions  were  seen  in  any  patient  that 
could  have  been  regarded  as  syphilitic. 

To  summarize  the  results,  of  the  38  cases  of  the  tubercular  and 
mixed  type,  the  reaction  was  negative  in  7,  weakly  positive  in  3, 
positive  in  21,  and  strongly  positive  in  7  cases.  Of  the  22  maculo- 
anesthetic  and  purely  anesthetic  cases,  the  reaction  was  negative  in 
19,  strongly  positive  in  1,  and  positive  in  2  cases. 

It  may  be  of  interest  to  add  that  beside  the  15  cases  of  leprosy 
examined  in  New  York,  I  have  also  seen  or  personally  known 
during  the  past  six  months,  of  7  other  cases  (3  of  Dr.  J.  McF.  Win- 
field,  and  one  each  of  Drs.  Wm.  B.  Trimble,  M.  B.  Parounagian, 
F.  M.  Dearborn,  and  G.  H.  Fox).  It  will  doubtless  seem  surprising 
to  some  that  there  should  have  been  so  many  cases  of  leprosy  in 
New  York  City  during  such  a  short  space  of  time. 

Cases  of  Tubercular  and  Mixed  Type  with  Positive 
Reaction.17  Case  I. — Patient  of  Dr.  S.  Dana  Hubbard,  service  of 
Dr.  Jackson,  Vanderbilt  Clinic.  I.  W.,  West  Indian  negress,  aged 
thirty-three  years.  Advanced  case  of  tubercular  type.  Duration 
of  disease  two  years.    Reaction:  strongly  positive. 

Case  II. — Patient  of  Dr.  G.  H.  Fox,  New  York  Skin  and  Cancer 
Hospital.  S.V.,  man,  aged  forty  years,  born  in  Russia.  Active 
fairly  advanced  case  of  mixed  type.  Duration,  two  years.  Reaction : 
Strongly  positive. 

15  The  Principles  and  Technique  of  the  Wassermann  Reaction  and  its  Modifications.  Med. 
Record,  1909,  p.  421;  a  Comparison  of  the  Wassermann  and  Noguchi  Complement  Fixation 
Tests,  Jour.  Cutan.  Dis.,  1909,  p.  338;  The  Wassermann  Reaction  (Noguchi  Modification) 
in  Pellagra,  New  York  Med.  Jour.,  1909,  p.  1206. 

16  On  Non-specific  Complement-fixation,  Proceed.  Soc.  Exper.  Biol,  and  Med.,  December, 
1909. 

17  Cases  not  designated  by  the  name  of  physician  and  name  of  clinic  where  treated,  were  all 
seen  at  the  Louisana  Leper  Home  in  the  service  of  Dr.  Isadore  Dyer. 


728 


fox:  wassermann  and  noguchi  fixation  test 


Case  III. — Patient  of  Dr.  G.  H.  Fox,  New  York  Skin  and  Cancer 
Hospital.  P.  N.,  man,  aged  forty-two  years,  Italian,  Armenian. 
Advanced  case  of  mixed  type.  Duration  said  to  be  two  years. 
Reaction:  Strongly  positive. 

Case  IV. — Patient  of  Dr.  G.  H.  Fox,  New  York  Skin  and  Cancer 
Hospital.  S.  V.,  man,  aged  twenty-seven  years,  Italian.  Very 
marked  active  case  of  tubercular  type.  Duration,  three  years. 
Reaction:  Positive. 

Case  V. — Patient  of  Dr.  L.  Duncan  Bulkley,  New  York  Skin 
and  Cancer  Hospital.  R.  R.,  Russian  woman,  aged  sixty  years. 
Advanced  case  of  mixed  type.  Duration,  ten  years.  Reaction: 
Positive. 

Case  VI.— Patient  of  Dr.  J.  McF.  Winfield,  Kings  County 
Hospital.  C.  W.,  negro,  aged  twenty-six  years,  born  in  United 
States.  Mixed  type  of  moderate  severity,  of  eight  years'  duration. 
Reaction :  Positive. 

Case  VII.—  Patient  of  Dr.  J.  McF.  Winfield,  Kings  County 
Hospital.  L.  M.,  man,  aged  about  fifty  years,  Russian.  Advanced 
case  of  mixed  type.  Duration,  about  twenty  years.  Reaction: 
Positive. 

Case  VIII.— Patient  of  Dr.  F.  M.  Dearborn,  Metropolitan  Hospi- 
tal. P.  L.,  Chinaman,  aged  thirty-nine  years.  Advanced  active 
case  of  mixed  type.    Duration  six  years.    Reaction:  Positive. 

Case  IX.— Patient  of  Dr.  Win.  S.  Gottheil,  City  Hospital.  China- 
man, aged  twenty-nine  years.  Moderate  case  of  tubercular  type, 
of  four  years'  duration.    Reaction:  Weakly  positive. 

Case  X.— Patient  of  Dr.  Win.  S.  Gottheil,  City  Hospital.  E.  G., 
man,  aged  twenty-seven  years,  born  in  Russia.  Mild  case  of  tuber- 
cular type.    Duration  three  and  a  half  years.    Reaction:  Positive. 

Case  XI.— Patient  of  Dr.  L.  Oulman,  German  Hospital.  L.  T., 
woman,  aged  twenty-four  years,  born  in  Russia.  Case  of  mixed 
type  of  moderate  severity.  Duration,  nine  years.  Reaction: 
Strongly  positive. 

Case  XII. — Colored  woman,  aged  fifty-seven  years,  active  tuber- 
cular case.    Duration  of  disease  four  years.    Reaction:  Positive. 

Case  XIII.— White  woman,  aged  forty-eight  years.  Advanced 
case  of  mixed  type.    Duration  fourteen  years.    Reaction:  Positive. 

Case  XIV. — White  woman,  aged  twenty-seven  years.  Case  of 
mixed  type.  Duration,  seven  years.  Patient  improving.  Reaction: 
Weakly  positive. 

Case  XV. — White  woman,  aged  fifty  years.  Mixed  type  of  the 
disease  in  an  advanced  stage.    Reaction:  Positive. 

Case  XVI. — 'White  woman,  aged  forty  years.  Advanced  and 
active  case  of  mixed  type.    Reaction:  Positive. 

Case  XVII. — Colored  woman,  aged  fifty  years.  Advanced  case 
of  tubercular  type.  Duration  of  disease,  three  years.  Reaction: 
Positive. 


fox:  wassermann  and  noguchi  fixation  test 


729 


Case  XVIII. — White  boy,  aged  sixteen  years.  Case  of  tubercular 
type.    Duration,  nine  years.    Reaction:  Positive. 

Case  XIX.  White  man,  aged  forty-eight  years.  Incipient  type, 
in  which  the  disease  is  active.  Duration,  five  years.  Reaction: 
Strongly  positive. 

Case  XX. — White  man,  aged  forty-five  years.  Advanced  case 
of  mixed  type.    Duration,  seventeen  years.    Reaction :  Positive. 

Case  XXI. — Colored  man,  aged  forty-eight  years.  Advanced 
case  of  mixed  type,  in  which  process  is  stationary.  Duration,  four 
years.    Reaction:  Positive. 

Case  XXII. — Colored  man,  aged  thirty-seven  years.  Active 
case  of  tubercular  type.  Duration,  five  years.  Reaction:  Weakly 
positive. 

Case  XXIII. — Colored  man,  aged  fifty  years.  Advanced  case 
of  mixed  type.  Disease  active.  Duration,  five  years.  Reaction: 
Strongly  positive. 

Case  XXIV. — White  boy,  aged  eighteen  years.  Terminal  case 
of  tubercular  type.  With  active  lesions.  Duration,  twelve  years. 
Reaction:  Positive. 

Case  XXV. — White  boy,  aged  nineteen  years.  Advanced  case 
of  mixed  type.    Duration,  five  years.    Reaction:  Positive. 

Case  XXVI. — White  boy,  aged  sixteen  years.  Advanced  case 
of  mixed  type.    Duration,  four  years.    Reaction:  Positive. 

Case  XXVII. — White  boy,  aged  twenty  years.  Incipient  case 
of  mixed  type,  relapsing  after  apparent  cure.  Duration,  nine  years. 
Reaction:  Strongly  positive. 

Case  XXVIII. — Colored  man,  aged  forty-two  years.  Terminal 
stage  of  mixed  type.    Duration,  three  years.    Reaction:  Positive. 

Case  XXIX. — White  woman,  aged  thirty-five  years.  Advanced 
active  case  of  mixed  type.  Duration,  fourteen  years.  Reaction: 
Positive. 

Case  XXX. — White  woman,  aged  fifty-seven  years.  Advanced 
case  of  mixed  type,  tubercles  having  disappeared.  Duration,  twenty 
years.    Reaction:  Positive. 

Case  XXXI. — White  man,  aged  forty  years.  Terminal  stage 
of  mixed  type.    Duration,  eight  years.    Reaction:  Positive. 

Cases  of  Tubercular  and  Mixed  Type  with  Negative 
Reaction.  Case  XXXII.— Patient  of  Dr.  Wm.  S.  Gottheil, 
City  Hospital.  H.  S.,  man,  aged  thirty-three  years,  born  in  the 
United  States.  Case  of  mixed  type  of  moderate  severity.  Duration, 
ten  years.    Reaction:  Negative. 

Case  XXXIII.— Patient  of  Dr.  F.  M.  Dearborn,  Metropolitan 
Hospital.  J.  M.,  man,  aged  fifty  years,  born  in  Russian  Poland. 
Case  of  mixed  type.  Very  few  lesions  at  present,  though  formerly 
well  marked.  Duration  of  disease  not  known  Has  been  in  leper 
ward  for  the  past  six  years.    Reaction"  Negative. 


730 


fox:  wassermann  and  noguchi  fixation  test 


/ 


Case  XXXIV. — White  man,  aged  twenty-eight  years.  Mixed 
type.  Patient  improving.  Duration  of  disease,  eighteen  years. 
Reaction:  Negative. 

Case  XXXV. — White  man,  aged  twenty-one  years.  Incipient 
case  of  mixed  type,  which  is  improving.  Duration,  six  years.  Reac- 
tion: Negative. 

Case  XXXVI.- — White  man,  aged  twenty-four  years.  Advanced 
case  of  mixed  type.  Disease  active.  Duration,  eighteen  years. 
Reaction :  Negative. 

Case  XXXVII. — Colored  man,  aged  twenty-six  years.  Terminal 
case  of  mixed  type.  Duration,  probably  five  years.  Reaction 
Negative. 

Case  XXXVIII. — White  woman,  aged  forty-three  years.  Case 
of  mixed  type,  improving,  tubercles  having  disappeared.  Duration, 
twenty  years.    Reaction:  Negative. 

Cases  of  Maculo-anesthetic  Type  with  Positive  Reac- 
tion. Case  XXXIX.— Patient  of  Dr.  G.  H.  Fox,  New  York  Skin 
and  Cancer  Hospital.  T.  D.,  girl,  born  in  Key  West,  Florida. 
Maculo-anesthetic  case  of  one  year's  duration.    Reaction:  Positive. 

Case  XL. — Colored  woman,  aged  sixty-four  years.  Incipient 
anesthetic  case.   Duration  three  years.   Reaction:  Strongly  positive. 

Case  XLT. — Colored  woman,  aged  fifty-nine  years.  Muculo- 
anesthetic  case,  improving.  Duration,  two  years.  Reaction:  Posi- 
tive. 

Cases  of  Maculo-anesthetic  Type  avith  Negative  Reac- 
tion. Case  XLIL— Patient  of  Dr.  J.  McF.  Winfield,  Kings 
County  Hospital.  J.  D.,  West  Indian  negro,  aged  twenty-nine  years. 
Maculo-anesthetic  type.  Duration,  about  twenty-three  years. 
Reaction:  Negative. 

Case  XLIII. — White  girl,  aged  seventeen  years.  Incipient  case 
of  maculo-anesthetic  type.  Duration,  fourteen  years.  Reaction: 
Negative. 

Case  XLIV. — White  woman,  aged  about  sixty  years.  Anesthetic 
type  in  advanced  stage.  Duration  of  the  disease,  unknown.  Reac- 
tion: Negative. 

Case  XLV.- -White  woman  about  fifty  years  of  age.  Advanced 
case  of  anesthetic  type.  Duration  of  the  disease,  unknown.  Reac- 
tion: Negative. 

Case  XL VI. — White  woman,  aged  about  fifty  years.  Incipient 
maculo-anesthetic  case.    Duration  unknown.    Reaction:  Negative. 

Case  XLVII. — White  woman,  aged  eighty-seven  years.  Incipient 
case  of  maculo-anesthetic  type.  Duration,  five  years.  Reaction: 
Negative. 

Case  XLVIII. — Colored  woman,  aged  fifty-three  years.  Ad- 
vanced anesthetic  case.  Duration,  twenty-seven  years.  Disease 
checked.    Reaction:  Negative. 


fox:  wassermann  and  noguchi  fixation  test 


731 


Case  XLIX. — Colored  woman,  aged  about  sixty  years.  Advanced 
anesthetic  case,  the  disease  being  stationary.  Duration,  fifteen 
years.    Reaction:  Negative. 

Case  L. — White  woman,  aged  thirty-four  years.  Maculo- 
anesthetic  case.  Former  tubercles  have  disappeared.  Duration, 
eight  years.    Reaction:  Negative. 

Case  LI. — White  boy,  aged  nineteen  years.  Advanced  case  of 
anesthetic  type.    Duration,  nine  years.    Reaction:  Negative. 

Case  LII. — White  man,  aged  forty  years.  Maculo-anesthetic 
type,  improving.    Duration,  fourteen  years.    Reaction:  Negative. 

Case  LIII. — White  girl,  aged  twelve  years.  Incipient  case  of 
maculo-anesthetic  type.   Duration,  four  years.   Reaction:  Negative. 

Case  LIV. — Colored  boy,  aged  nine  years.  Incipient  case  of 
maculo-anesthetic  type.   Duration,  four  years.   Reaction:  Negative. 

Case  LV. — White  man,  aged  forty- three  years.  Advanced  case 
of  anesthetic  type.  Duration,  thirty  years.  Disease  arrested. 
Reaction:  Negative. 

Case  LVI. — White  man,  aged  fifty-four  years.  Incipient  case 
of  anesthetic  type.    Duration  ten  years.    Reaction:  Negative. 

Case  LVII. — White  man,  aged  fifty-eight  years.  Terminal  case 
of  anesthetic  type.    Duration,  thirty  years.   Reaction :  Negative. 

Case  LVTII. — White  man,  aged  fifty-six  years.  Terminal  stage 
of  anesthetic  type.    Duration,  thirty  years.    Reaction:  Negative. 

Case  LIX. — Chinaman,  aged  seventy-five  years.  Anesthetic 
case  of  thirteen  years'  duration.    Reaction:  Negative. 

Case  LX. — White  man,  aged  forty-six  years.  Advanced  anes- 
thetic case.  Patient  claims  to  have  been  discharged  cured  from  a 
Norwegian  hospital  twenty  years  ago.  Duration,  twenty-five  years. 
Reaction:  Negative. 

Conclusions.  1.  A  positive  Wassermann  reaction  is  frequently 
obtained  in  cases  of  leprosy  giving  no  history  or  symptoms  whatever 
of  syphilis. 

2.  The  reaction  is  at  times  very  strong,  inhibition  of  hemolysis 
being  complete. 

3.  The  reaction  occurs  chiefly  in  the  tubercular  and  mixed  forms 
of  the  disease,  especially  in  advanced  and  active  cases. 

4.  In  the  cases  of  the  maculo-anesthetic  and  purely  trophic  type 
the  reaction  is  generally  negative. 

5.  The  value  of  the  test  is  not  affected  in  the  slightest  by  the 
results  found  in  leprosy. 

In  closing,  I  desire  to  express  my  thanks  to  Dr.  Isadore  Dyer  for 
kindly  putting  at  my  disposal  the  splendid  material  of  the  Louisiana 
Leper  Home.  I  also  wish  to  thank  Dr.  Ralph  Hopkins,  the  attend- 
ing physician  to  the  Leper  Home  for  aid  in  obtaining  case  histories. 
For  the  material  in  New  York  I  am  indebted  to  the  physicians 
whose  names  have  been  mentioned  in  the  text. 


732 


francine:  tuberculosis 


THE  EFFECT  OF  TUBERCULOSIS  ON  INTRATHORACIC 
RELATIONS.1 

By  Albert  Philip  Francine  A.M.,  M.D., 

INSTRUCTOR  IN   MEDICINE  IN   THE  UNIVERSITY   OF   PENNSYLVANIA;   VISITING   PHYSICIAN  TO 
THE    DEPARTMENT    OF  TUBERCULOSIS  OF  THE   PHILADELPHIA  GENERAL  HOSPITAL; 
PHYSICIAN-IN-CHIEF  TO  THE  STATE  TUBERCULOSIS  DISPENSARY,  PHILADELPHIA. 

The  following  preliminary  report  deals  with  the  changes  brought 
about  in  intrathoracic  relations  as  shown  by  skiagrams  of  cases 
of  pulmonary  tuberculosis,  studied  clinically  before  and  after 
the  taking  of  the  a?-ray  plates.  I  will  confine  myself  simply  to 
the  more  salient  features  of  this  study,  which  deals  with  the  altera- 
tions in  the  position  of  aorta,  heart,  and  diaphragm.  The  presence 
or  absence,  of  enlarged  bronchial  glands,  and  of  calcareous  infiltra- 
tion in  the  costal  cartilages  of  the  ribs  is  also  briefly  considered. 

When  such  a  study  is  carried  out  with  technical  precision,  it 
would  seem  to  leave  little  room  for  error;  because  with  the  use 
of  the  modern  tubes  and  coils,  and  instantaneous  exposures,  the 
resulting  skiagrams  are  so  clear  cut  and  definitive  as  to  give  an 
admirable  geographical  chart.  I  believe  that  such  a  study  gives 
more  satisfactory  results  in  regard  to  the  position  of  the  organs 
in  life  than  those  obtained  by  autopsy,  for  in  the  latter  there  is 
the  postmortem  change,  due  to  alteration  in  intrathoracic  pressure 
or  to  other  strictly  postmortem  influences;  there  is  also  the 
trauma  of  the  autopsy  and  consequent  derangement  of  relations, 
and  finally  there  is  the  question  of  elapsed  time.  I  feel  further 
that  purely  clinical  studies  of  this  nature,  when  unconfirmed  by 
rontgenology,  are  without  much  accuracy  or  value,  except  in  so  far 
as  in  certain  instances  the  personal  equation  of  the  investigator 
has  given  them  such. 

The  value  of  roentgenography  in  the  study  of  pulmonary  tuber- 
culosis, as  supplementary  to  physical  examination,  is  so  generally 
recognized  as  to  need  no  exposition.  I  shall  not  discuss  the  use 
of  the  arrays  from  the  standpoint  of  early  diagnosis,  but  in  their 
relations  to  the  later  pathological  changes.  Rontgenology  must 
not,  of  course,  be  considered  as  having  solved  the  problems  of 
physical  diagnosis  of  the  chest,  but  it  helps  to  elucidate  them  and 
to  confirm  the  clinical  findings.  It  has  not  and  never  can  supplant 
nor  minimize  the  importance  of  the  time-honored  clinical  methods, 
but  should  on  the  contrary  serve  a  useful  purpose  in  stimulating 
more  exact  methods,  because  the  possibilities  of  physical  diagnosis 
are  extended  from  the  information  and  suggestions  gleaned  from 
the  x-mys. 

The  cases  from  which  this  study  is  made  were  skiagraphed  by 

1  Read  at  the  XVI  International  Medical  Congress,  Budapest,  August,  1909. 


FRANCINE:  TUBERCULOSIS 


733 


Dr.  Charles  Lester  Leonard,  of  Philadelphia,  and  were  in  some 
instances  patients  from  the  Pennsylvania  State  Dispensary, 
No.  21,  for  Tuberculosis,  and  in  others  from  private  practice. 
The  majority  of  the  cases  were  moderately  advanced  and  advanced 
cases  (Class  II  and  III  of  the  National  Association  classification), 
though  the  only  selection  used  was  in  the  financial  ability  of  the 
patient  to  bear  the  expense  of  the  skiagrams.  The  number  here 
reported  is  too  small  (that  is,  60  cases)  to  warrant  me  in  drawing 
any  very  definite  conclusions,  but  the  results  are  at  least  suggestive, 
and  the  conclusions  which  I  do  present  relate  only  to  this  series. 

I  shall  not  attempt  at  this  time  to  discuss  the  data  gleaned  from 
this  study,  in  the  light  of  present  knowledge  or  views,  but  shall 
content  myself  with  merely  recording  the  details  noted,  pointing 
out  where  in  certain  instances  the  conclusions  drawn  are  at  variance 
with  the  views  or  opinions  of  others. 

The  Aorta  and  Heart.  It  should  be  noted  that  quite  fre- 
quently in  advanced  pulmonary  tuberculosis  the  aorta  is  displaced 
as  well  as  the  heart  and  in  the  same  direction,  usually  to  the  right. 
In  marked  displacements  of  the  heart  this  is  the  rule  (Cases  II, 
IV,  VI,  XII,  XIII,  XXV,  XXVII,  XXVIII,  XLVI,  XLVII,  LII, 
LIX).  Rarely  the  aorta  may  be  drawn  out  of  position,  while  the 
heart  is  unaffected  (Case  XXXIII).  The  error  is  sometimes  made  of 
interpreting  the  physical  signs  of  a  displaced  aorta,  as  being  those 
of  enlarged  glands  or  of  aneurysmal  dilatation.  With  an  area  of 
dulness  to  the  right  of  the  sternum  in  the  second  or  third  interspace 
and  much  displacement  of  the  heart,  the  conclusion  that  the  aorta 
is  displaced  is  warranted,  in  the  absence  of  definite  signs  of  aneurysm. 
Rarely  an  aneurysmal  dilatation  of  the  aorta  may  be  present. 

It  is  noteworthy  that  in  the  present  series,  many  of  which  were 
advanced  or  far  advanced  cases,  the  heart  in  the  majority  of 
instances  was  not  displaced.  There  seems  no  doubt  about  this 
conclusion,  and  I  therefore  feel  that  those  who  hold  that  dis- 
placement of  the  heart  is  a  reasonably  constant  sign  or  accom- 
paniment of  pulmonary  tuberculosis  are  in  error.  Turban  makes 
the  statement  that  "it  is  exceptional  to  find  the  heart  in  its  normal 
position  in  advanced  chronic  tuberculosis,"2  while  Pottenger  says 
that  displacement  of  the  heart  is  a  "typical  and  cardinal  symptom" 
of  tuberculosis  of  the  right  apex.3 

In  63.33  per  cent,  of  the  cases  the  heart  was  not  displaced  (that 
is,  in  38  cases,  I,  III,  V,  VII,  VIII,  X,  XI,  XIII,  XIV,  XVI,  XVII, 
XIX,  XX,  XXI,  XXII,  XXIII,  XXIV,  XXVI,  XXVIII,  XXIX, 
XXX,  XXXII,  XXXIII,  XXXV,  XXXVII,  XL,  XLI,  XLIV, 
XLVIII,  XLIX,  L,  LI,  LIII,  LIV,  LV,  LVI,  LVII,  LX). 

Absence  of  displacement  is  much  more  common,  in  fact  almost 


2  Diagnosis  and  Treatment  of  Pulmonary  Tuberculosis,  1908 

3  Diagnosis  of  Tuberculosis  of  the  Lungs,  1906. 


734 


FRANCINE :  TUBERCULOSIS 


the  rule,  in  acute  infiltrations  and  consolidations  before  fibrosis 
and  contraction  have  taken  place.  In  many  instances  even  when 
the  lesions  were  widespread  and  often  destructive,  the  heart  was 
not  displaced.  (Cases  I,  III,  VIII,  XI,  XIII,  XIV,  XVI,  XVII, 
XX,  XXII,  XXIII,  XXIV,  XXXII,  XXXIII,  XXXV,  XLVIII, 
XLIX,  L,  LI,  LVII).  In  Case  XIII,  with  cavitation  at  the  right 
apex  and  infiltration  of  the  entire  upper  lobe,  the  heart  was  not  dis- 
placed, due  to  pericardial  adhesions  over  apex  which  could  be 
plainly  seen.  In  Case  XXIII,  with  large  cavities  in  both  apices 
and  much  fibrosis,  the  heart  was  not  displaced,  possibly  on  account 


Fig.  1. — Case  XXIV.     Left-sided  localized  pneumothorax  without  displacement  of  the 
heart.     The  case  belongs  to  Class  III  of  the  National  Association  classification. 


of  the  symmetrical  character  of  the  lesions,  or  possibly  from  adhe- 
sions. In  Case  XXIV  (Fig.  1),  with  left-sided  localized  pneumo- 
thorax, the  heart  was  not  displaced.  In  Case  XXXIII,  with  a  large 
cavity  on  the  right  and  complete  consolidation  of  the  right  upper 
lobe,  and  moderate  infiltration  on  the  left,  the  heart  was  not  dis- 
placed.   In  the  following  far-advanced  cases  with  cavity  the  heart 


was  not  displaced:  Cases  XI,  XIII,  XIV,  XXIII,  XXIV,  XXXIII, 
XLVIII,  XLIX,  L. 

The  heart  was  displaced  in  36.66  per  cent,  of  this  series,  in  15 
cases  to  the  right  (Cases  II,  IV,  XII,  XV,  XXV,  XXVII,  XXXVI, 


francine:  tuberculosis 


735 


XXXVIII,  XLIII,  XLV,  XLVI,  XLVII,  LII,  LVIII,  LIX);  in  3 
cases  to  the  left  (Cases  VI,  IX,  XXXI);  and  in  4  cases  in  the  antero- 
posterior position  (Cases  XVIII,  XXXIV,  XXXIX,  XLII),  to 
be  described  later.  I  cannot,  therefore,  agree  with  the  statement 
of  Lawrason  Brown4  that  "  marked  displacement  of  the  heart 
occurs  much  more  frequently  to  the  left  than  the  right." 

On  the  contrary,  when  the  pulmonary  lesions  are  of  fairly  symmet- 
rical character  on  both  sides,  the  heart  is  more  commonly  displaced  to 
the  right  than  to  the  left  (Cases  II,  XXV,  XXXVI,  LII,  LVIII, 


Fig.  2. — The  heart  in  the  anteroposterior  position.     Destructive  lesions  at  both  apices. 
The  case  belongs  to  Class  III  of  the  National  Association  classification. 

LIX.)  In  these  cases  there  is  usually  evidence  to  show  that  the 
primary  and  older  lesion  is  on  the  right.  When  the  lesion  is  more 
extensive  on  the  left  the  heart  is  not  so  regularly  displaced  nor  to  the 
same  extent,  as  in  corresponding  right-sided  lesions  (Cases  I,  III, 
XIV).  In  Case  XIV,  with  cavity  in  the  left  apex  and  consolidation 
of  the  lung  below,  and  moderate  infiltration  of  the  right  apex,  the  heart 
was  not  displaced.  Rarely  the  fibrosis  of  the  lungs  and  pleura?  may 
be  so  great  or  of  sufficient  density  to  obliterate  the  boundaries  of 
the  heart  (Case  IX). 

4  Amer.  Jouit.  Med.  Sci.,  1908. 


736 


francine:  tuberculosis 


In  4  cases  the  heart  occupied,  what  for  want  of  a  better  term,  I  have 
called  the  anteroposterior  position  (Cases  XVIII,  XXXIV,  XXXIX, 
XLII).  In  this  position  (Figs.  2  and  3)  the  heart  assumes  along  narrow 
appearance,  as  if  it  were  turned  upon  its  vertical  axis.  It  should 
be  noted  that  in  all  these  cases,  there  were  far  advanced  destructive 
lesions  on  both  sides,  and  it  might  appear  that  the  combined  effect 
of  the  traction  exerted  under  these  conditions,  had  resulted  in 
drawing  the  heart  upward  and  inward,  thus  causing  the  apex  to 
swing  around.    In  long  narrow  chests  the  heart  assumes  a  more 


Fig.  3. — The  heart  in  the  anteroposterior  position.    Destructive  lesions  at  both  apices. 
The  case  belongs  to  Class  III  of  the  National  Association  classification. 

oblique  position.  The  angle  formed  with  the  liver  on  the  right 
is  less  acute  and  the  left  boundary  is  appreciably  more  vertical. 
The  heart  also  assumes  an  appreciably  more  oblique  position  during 
deep  inspiration. 

In  many  cases  the  skiagrams  show  an  interesting  feature  which 
is  not  demonstrable  clinically,  namely,  that  during  systole  of  the 
heart  there  is  an  area  between  the  lower  boundary  of  the  heart 
and  the  diaphragm  of  about  the  extent  of  one  centimeter,  which 
distinctly  transmits  the  x-rays.  The  limits  or  extent  of  the  cardiac 
excursion  may  also  be  seen  in  many  cases.    In  four  cases,  distinct 


FRANCINE I  TUBERCULOSIS 


737 


pericardial  adhesions  could  be  seen  (Cases  VII,  XI,  XIII,  XVIII) 
The  heart  appeared  normal  in  size  both  in  the  x-raj  plates  anj 
to  physical  examination  in  all  the  cases  with  four  exceptions 
(Cases  XIX,  XXIII,  LVI,  LIV).  In  three  of  these  the  enlarge- 
ment was  practically  confined  to  the  right  side,  and  the  lungs  were 
markedly  emphysematous.  In  Case  XIX  there  was  a  general 
hypertrophy.  There  was  no  evidence  of  an  organic  valvular 
lesion  in  the  series,  though  in  some  cases  soft  systolic  murmurs 
were  audible  in  the  mitral  and  pulmonary  areas. 

The  Diaphragm.  The  skiagrams  were  taken  under  full  inspira- 
tion. In  29  cases  (48.33  per  cent.)  the  diaphragm  was  unaffected 
by  the  pulmonary  lesion  (Cases  I,  III,  V,  VII,  X,  XI,  XIII,  XVII, 
XIX,  XX,  XXI,  XXIV,  XXVI,  XXVIII,  XXIX,  XXX,  XXXII, 
XXXV,  XL,  XLI,  XLIV,  XLVIII,  LI,  LIV  LV,  LVI,  LVII, 
LX);  the  diaphragm  was  affected  in  this  series  in  51.66  per  cent, 
of  the  cases.  In  13  cases  it  was  elevated  on  the  right  side  (Cases 
II,  VIII,  XII,  XV,  XVI,  XXII,  XXV,  XXXVIII,  XLIII,  XLV, 
XLIX,  L,  LVIII);  in  5  cases  on  the  left  (Cases  VI,  XIV,  XXVII, 
XXXI,  LIII);  in  7  cases  it  was  elevated  on  both  sides  (Cases 
XVIII,  XXIII,  XXXIII,  XXXIV,  XXXVI,  XXXIX,  XLII); 
and  in  6  cases  it  was  not  visible  or  determinable  on  account  of  the 
density  of  the  adjacent  involvement  of  the  lungs  and  pleura  (Cases 
IV,  IX,  XLVI,  XLVII,  LII,  LIX). 

In  every  case  in  which  the  heart  was  displaced  the  diaphragm  was 
elevated  on  the  side  toward  the  displacement,  and  in  the  cases  in 
which  the  heart  assumed  the  anterc  posterior  position  the  diaphragm 
was  elevated  on  both  sides.  There  was  one  exception  to  this  rule 
which  does  not  properly  apply  as  such,  but  in  Case  XXVII,  which 
had  been  operated  on  for  left-sided  empyema  some  years  previously, 
there  was  collapse  of  the  chest  wall,  with  consequent  dragging 
upward  of  the  diaphragm  on  that  side,  while  the  heart  was  dis- 
placed to  the  right. 

The  diaphragm  was  affected  in  9  cases  in  which  the  position 
of  the  heart  was  normal  (Cases  VIII,  XIV,  XVI,  XXII,  XXIII, 
XXXIII,  XLIX,  L,  LIII)  (Fig.  4).  In  other  words,  the  diaphragm 
was  more  sensitive  to,  or  affected  by,  the  presence  of  a  pulmonary 
lesion  than  the  heart  in  15  per  cent,  of  the  cases.  This  was  true 
in  5  advanced  cases  (Cases  VIII,  XIV,  XXXIII,  XLIX,  L),  as 
well  as  in  4  of  the  earlier  cases  (XVI,  XXII,  XXIII,  LIII);  and 
yet  in  10  advanced  cases  in  which  one  would  have  expected  to  find 
the  diaphragm  affected,  it  was  not  apparent  (except  in  limitation 
of  pulmonary  excursion),  either  to  physical  examination  or  in  the 
plates  (Cases  I,  III,  XI,  XIII,  XVII,  XXIV,  XXXV,  XLVIII, 
LI,  LVII).  Thus  in  cases  of  relatively  slight  involvement  the 
diaphragm  may  be  elevated  on  the  affected  side  (Case  XXII,  as 
type);  while  in  cases  with  marked  involvement  and  even  cavita- 
tion the  diaphragm  may  not  be  elevated  (Case  XIII  as  a  type). 


738 


francine:  tuberculosis 


Thus  the  diaphragm  had  responded,  in  change  of  position,  to  the 
pulmonary  lesion  in  only  half  the  cases. 

The  Peribronchial  Lymph  Nodes.  In  every  case  in  this 
series  the  cervical  glands  were  enlarged  to  palpitation.  It  would 
seem  probable  that  the  peribronchial  glands  would  also  be  affected 
in  all  cases,  though  this  could  not  be  deduced  from  the  skiagrams. 
In  51.66  per  cent,  of  the  cases  enlarged  glands  could  be  seen  in 
the  plates  (Cases  V,  VII,  VIII,  X,  XIII,  XVII,  XVIII,  XIX, 
XX,  XXI,  XXII,  XXIII,  XXVI,  XXVII,  XXVIII,  XXIX,  XXX, 


Fig.  4. — Showing  the  heart  in  the  normal  position,  with  the  diaphragm  elevated  on  the 
right.  The  enlarged  peribronchial  glands  show  well.  The  case  belongs  to  Class  I  of  the 
National  Association  classification. 

XXXIV,  XXXVII,  XL,  XLI,  XLIII,  XLIV,  L,  LI,  LIII,  LIV, 
LVI,  LVII,  LVIII,  LX;  31  cases).  With  the  exception  of  about 
6  cases  (Cases  XIII,  XVIII,  XXIII,  XXXIV,  XLIII,  L)  all  the 
cases  in  which  enlarged  glands  were  visible  were  either  early  or 
moderately  advanced,  without  the  breaking  down  of  tissue;  while 
in  the  large  majority  of  the  advanced  cases  the  glands  did  not  show. 
It  would  then  appear  as  if  there  were  two  explanations  for  the 
absence  of  glands  in  the  majority  of  plates  in  which  they  were  not 
visible,  namely,  that  their  presence  was  concealed  by  the  area 
of  involvement,  or  what  appears  more  likely,  that  with  the  advance 


FliANCINE :  TUBERCULOSIS 


739 


of  the  disease  the  glands  had  softened  or  broken  down  and  so 
failed  to  give  rise  to  a  shadow.  There  were  usually  only  three 
or  four  glands  noted  in  any  one  plate,  and  in  a  number  of  instances 
they  appeared  to  be  calcified. 

Calcification  of  Costal  Cartilages.  The  presence  of 
calcareous  infiltration  in  the  costal  cartilages  was  noted  in  only 
8  cases  (Cases  I,  VIII,  XIII,  XXVI,  XLIV,  LII,  LVI,  LVIII). 
It  would  appear  to  be  grossly  absent  in  many  cases  in  which  its 
presence  might  be  expected  and  in  which  it  could  no  doubt,  be  demon- 
strated microscopically;  it  was  generally  noted  in  the  advanced 
chronic  type  of  the  disease,  though  there  were  exceptions  to  this. 
It  was  usually  confined  to  the  costal  cartilage  of  the  first  rib,  though 
in  one  instance  it  involved  them  all  (Case  VIII).  In  the  majority 
of  the  advanced  cases  the  involvement  was  of  sufficient  density 
and  extent  to  have  concealed  the  presence  of  calcification  in  the 
cartilages  of  the  first  rib,  but  there  was  no  evidence  of  calcification 
in  the  costal  cartilages  which  could  be  properly  studied. 

Summary  of  Cases.  Case  I. — F.,  adult  female.  Infiltration 
of  upper  right  lobe.  Consolidation  of  left  upper  lobe.  Lesion 
more  extensive  and  active  on  left.  Heart  normal  in  position  and 
size.  No  glands  visible.  Diaphragm  not  elevated.  Calcareous 
infiltration  costal  cartilage  first  rib.    (Class  III,  N.  A.5) 

Case  II. — A.,  adult  male.  Marked  consolidation  and  fibrosis 
of  upper  half  right  lung,  with  large  cavity  in  upper  lobe.  Infiltra- 
tion of  left  upper  lobe,  cavity,  with  pneumonic  consolidation  left 
lower  lobe.  Heart  completely  displaced  to  right.  Aorta  markedly 
pulled  over.  Heart  normal  in  size.  No  glands  visible.  Dia- 
phragm elevated  on  right.  Costal  cartilages  concealed  by  lesion. 
(Class  III.) 

Case  III. — H.,  adult  male.  Infiltration  of  right  apex  and  left 
upper  lobe.  Heart  normal  in  size  and  position.  No  glands  visible. 
Diaphragm  normal.    No  calcification  of  costal  cartilages.  (Class 

id 

Case  IV. — N.,  adult  male.  Left-sided  hydropneumothorax. 
Left  lung  completely  collapsed.  Disseminated  lesions  through- 
out right  lung.  Complete  displacement  of  heart  and  aorta  to  right. 
Heart  normal  in  size.  No  glands  visible.  Diaphragm  not  visible 
on  left.    No  calcification.    (Class  III.) 

Case  V. — O'C,  boy,  aged  twelve  years.  Peribronchial  infiltra- 
tion on  both  sides  radiating  into  apices.  Peribronchial  glands 
enlarged.  Heart  normal  in  size  and  position.  Diaphragm  normal. 
No  calcification.    (Class  I.) 

Case  VI. — J.,  adult  female.  Small  cavity  left  apex  with  con- 
solidation (fibroid)  of  left  upper  lobe.    Slight  infiltration  right 

6  N.  A. — National  Association  for  the  Study  and  Prevention  of  Tuberculosis. 


740 


FRANCINE :  TUBERCULOSIS 


apex.  Heart  displaced  moderately  to  left.  Aorta  also  displaced. 
Heart  normal  in  size.  No  glands  visible.  Diaphragm  slightly 
raised  on  left.    No  calcification.    (Class  II.) 

Case  VII. — J.,  adult  male.  Slight  infiltration  on  right.  Early 
case.  Heart  normal  in  size  and  position.  Pericardial  adhesion 
at  apex.  Peribronchial  glands  enlarged.  Diaphragm  normal. 
No  calcification.    (Class  I.) 

Case  VIII. — J.,  adult  female.  Fibroid  consolidation  both  upper 
lobes,  more  marked  on  right.  Heart  normal  size  and  position. 
Peribronchial  glands  enlarged,  diaphragm  elevated  on  right. 
Marked  calcification  of  all  costal  cartilages.    (Class  II.) 

Case  IX. — M.,  adult  male.  Large  cavity  at  left  apex,  with 
complete  fibroid  consolidation  of  rest  of  lung.  Left  pleura  greatly 
thickened.  Consolidation  of  right  upper  lobe.  Heart  not  dis- 
tinguishable in  skiagram,  clinically  displaced  to  left.  Diaphragm 
not  visible  on  left.   No  glands  visible   No  calcification.    (Class  III.) 

Case  X. — M.,  adult,  male.  Infiltration  of  both  apices.  Heart 
normal  size  and  position.  Peribronchial  glands  enlarged.  Dia- 
phragm normal.    No  calcification.    (Class  II.) 

Case  XI. — S.,  adult,  male.  Small  cavitation  right  apex,  with 
consolidation  right  upper  lobe.  Consolidation  left  upper  lobe. 
Heart  normal  in  size  and  position.  Pericardial  adhesion.  No 
glands  visible.    Diaphragm  normal.    No  calcification.    (Class  III.) 

Case  XII. — A.,  adult  male.  Infiltration  right  apex  with  marked 
fibrosis  of  right  lower  lobe.  Left  lung  clear.  Heart  and  aorta 
much  displaced  to  right.  Diaphragm  much  elevated  on  right. 
No  glands  visible.    No  calcification.    (Class  II.) 

Case  XIII. — D.,  adult,  male.  Small  cavity  right  apex,  with 
infiltration  of  right  upper  lobe.  Slight  infiltration  left  apex.  Heart 
normal  size  and  position.  Pericardial  adhesions  at  apex.  Glands 
enlarged.  Diaphragm  normal.  Calcification  first  left  costal  cartil- 
age.   (Class  II.)  f  -  i 

Case  XIV. — R.,  adult,  female.  Cavity  left  apex  with  consolida- 
tion both  left  lobes.  Infiltration  right  apex.  Heart  normal  size 
and  position.  Diaphragm  elevated  on  left.  No  glands.  No 
calcification.    (Class  III.) 

Case  XV. — D.,  adult,  male.  Large  cavity  right  upper  lobe, 
consolidation  right  upper  lobe.  Small  cavity  left  upper  lobe, 
with  infiltration  of  left  upper  lobe.  Heart  displaced  to  right,  normal 
in  size.  Diaphragm  elevated  on  right.  No  glands.  No  calcifi- 
cation.   (Class  III.) 

Case  XVI. — E.,  adult,  male.  Infiltration  of  both  apices,  more 
marked  on  right.  Heart  normal  in  size  and  position.  No  glands. 
Diaphragm  elevated  on  right.    No  calcification.    (Class  II.) 

Case  XVII. — V.,  adult,  male.  Infiltration  both  apices,  more 
marked   on   right.    Heart   normal,   size  and  position.  Glands 


FRANCINE :  TUBERCULOSIS 


741 


enlarged.  Heart  normal,  size  and  position.  Diaphragm  normal. 
No  calcification.    (Class  II.) 

Case  XVIII. — R.,  adult,  male.  Large  cavity  right  apex,  another 
in  upper  lobe,  with  marked  consolidation  of  middle  lobe.  Small 
cavity  left  apex  with  consolidation  of  left  upper  lobe.  Antero- 
posterior position  of  heart.  Aorta  displaced  to  right.  Pericardial 
adhesion  right  side.  Glands  enlarged.  Diaphragm  elevated 
equally  both  sides.    No  calcification.    (Class  III.) 

Case  XIX. — S.,  girl,  aged  seventeen  years.  Infiltration  of  right 
apex,  marked  emphysema.  Heart  normal  position.  Glands  en- 
larged. Diaphragm  normal.  No  calcification.  General  hyper- 
trophy of  heart.    (Class  I.) 

Case  XX. — S.,  adult,  female.  Infiltration  left  upper  lobe. 
Heart  normal,  size  and  position.  Diaphragm  normal.  Glands 
enlarged.    No  calcification.    (Class  II.) 

Case  XXI. — V.,  adult,  male.  Infiltration  roots  of  both  lungs, 
radiating  into  apices.  Heart  normal  size  and  position.  Dia- 
phragm normal.    Glands  enlarged.    No  calcification.    (Class  I.) 

Case  XXII. — D.,  adult,  female.  Infiltration  right  upper  lobe. 
Heart  normal  size  and  position.  Glands  enlarged.  Diaphragm 
elevated  on  right.    No  calcification.    (Class  II.) 

Case  XXIII. — C,  adult,  male.  Cavities  both  apices,  with 
consolidation  both  upper  lobes.  Marked  emphysema.  Heart 
normal  in  position,  enlarged  to  right.  Diaphragm  elevated  both 
sides.    Glands  enlarged.    No  calcification.    (Class  III.) 

Case  XXIV. — Z.,  adult,  male.  Cavity  left  upper  lobe.  Left- 
sided  localized  pneumothorax  over  partially  collapsed  lung,  Heart 
normal  in  size  and  position.  Diaphragm  depressed  on  left.  No 
glands  visible.    No  calcification.    (Class  III.) 

Case  XXV. — D.,  adult,  male.  Cavity  right  apex,  consolidation 
right  upper  lobe.  Cavity  left  apex.  Consolidation  left  upper 
lobe.  Heart  and  aorta  much  displaced  to  right.  Heart  normal 
in  size.  Diaphragm  elevated  on  right.  No  glands.  No  calcifica- 
tion.   (Class  III.) 

Case  XXVI. — J.,  adult,  female.  Infiltration  both  apices. 
Tuberculous  glands  of  neck  (operative).  Heart  normal  ni  size 
and  position.  Glands  enlarged.  Diaphragm  normal.  Calcifica- 
tion of  costal  cartilage  (left).    (Class  II.) 

Case  XXVII. — S.,  adult,  female.  Left-sided  emphysema 
(operative)  complete  collapse  of  left  lung.  Heart  almost  com- 
pletely displaced  to  right.  Aorta  displaced  to  right.  Diaphragm 
much  elevated  on  left.    Glands  enlarged.    No  calcification.  (Class 

ra-) 

Case  XXVIII. — P.,  boy.  Infiltration  right  apex.  Localized 
empyema  on  right.  Fibrosis  right  lower  lobe  and  pleura.  Heart 
and  aorta  not  displaced.  Diaphragm  normal.  No  calcification. 
Glands  enlarged.    (Class  III.) 


742 


FRANCINE :  TUBERCULOSIS 


Case  XXIX. — P.,  adult,  female.  Consolidation  left  apex. 
Heart  normal  size  and  position.  Glands  enlarged.  Diaphragm 
normal.    No  calcification.    (Class  I.) 

Case  XXX. — U.,  adult,  female.  Infiltration  right  apex.  Heart 
normal  size  and  position.  Glands  enlarged.  Diaphragm  normal. 
No  calcification.    (Class  I.) 

Case  XXXI. — H.,  adult,  female.  Cavity  left  apex.  Consolida- 
tion left  upper  lobe,  disseminated  lesions  below.  Infiltration  right 
apex.  Heart  slightly  displaced  to  left.  Diaphragm  elevated  on 
left.    No  glands.    No  calcification.    (Class  III.) 

Case  XXXII. — B.,  adult,  male.  Infiltration  both  apices.  Heart 
normal  size  and  position.  Glands  enlarged.  Diaphragm  normal. 
No  glands.    No  calcification.    (Class  II.) 

Case  XXXIII. — A.,  adult,  female.  Large  cavity  right  apex, 
with  consolidation  right  upper  lobe.  Infiltration  left  upper  lobe. 
Heart  normal  size  and  position.  Aorta  much  displaced  to  right. 
Diaphragm  elevated  both  sides.  No  glands.  No  calcification. 
(Class  III.) 

Case  XXXIV. — C,  adult,  male.  Cavities  upper  right  lobe, 
with  consolidation  and  marked  calcification  on  right.  Cavity 
left  apex  with  marked  consolidation  and  fibrosis.  Heart  in  antero- 
posterior position.  Diaphragm  elevated  on  both  sides.  No 
calcification  of  costal  cartilage.    Calcified  glands.    (Class  III.) 

Case  XXXV. — O.,  adult,  male.  Consolidation  right  upper 
and  middle  lobes.  Infiltration  of  left  upper  lobe.  Heart  normal 
size  and  position.  Diaphragm  normal.  No  glands.  No  calcifi- 
cation.   (Class  III.) 

Case  XXXVI. — C,  adult,  male.  Cavity  at  both  apices,  with 
consolidation  and  fibrosis  of  both  upper  lobes.  Heart  displaced 
to  right,  Diaphragm  elevated  on  both  sides.  No  glands.  No 
calcification.    (Class  III.) 

Case  XXXVII. — S.,  adult,  male.  Infiltration  both  apices. 
Heart  normal  size  and  position.  Glands  enlarged.  Diaphragm 
normal.    No  calcification.    (Class  II.) 

Case  XXXVIII. — O.,  adult,  female.  Large  cavity  right  apex, 
consolidation  of  right  upper  lobe.  Infiltration  left  upper  lobe. 
Heart  displaced  to  right.  Diaphragm  elevated  on  right.  No 
glands.    No  calcification.    (Class  III.) 

Case  XXXIX. — D.,  adult,  male.  Large  cavity  left  apex,  con- 
solidation left  upper  lobe.  Infiltration  right  apex.  Heart  in 
anteroposterior  position.  Diaphragm  elevated  both  sides.  No 
glands.    No  calcification.    (Class  III.) 

Case  XL. — McV.,  adult,  male.  Infiltration  right  apex.  Heart 
normal  size  and  position.  Glands  enlarged.  Diaphragm  normal. 
No  calcification.    (Class  I.) 


FRANCINE :  TUBERCULOSIS 


743 


Case  XLI. — R.,  adult,  female.  Slight  infiltration  right  apex. 
Heart  normal  size  and  position.  Glands  enlarged.  Diaphragm 
normal.    No  calcification.    (Class  I.) 

Case  XLII. — T.,  adult,  male.  Large  cavity  right  apex.  Con- 
solidation and  fibrosis  right  upper  and  middle  lobes.  Cavity  left 
apex  consolidation,  left  upper  lobe.  Heart  in  anteroposterior 
position.  Diaphragm  elevated  on  both  sides.  No  glands  visible. 
No  calcification.    (Class  III.) 

Case  XLIII. — M.,  adult,  female.  Cavities  in  right  upper  lobe, 
with  consolidation  and  fibrosis.  Consolidation  left  upper  lobe. 
Heart  displaced  to  right.  Diaphragm  elevated  on  right.  Glands 
enlarged.    No  calcification  visible.    (Class  III.) 

Case  XLIV. — McG.,  adult,  male.  Infiltration  of  right  apex. 
Heart  normal  size  and  position.  Diaphragm  normal.  Calcifica- 
tion of  costal  cartilage.    Glands  enlarged.    (Class  I.) 

Case  XLV. — G.,  adult,  male.  Large  cavity  right  upper  lobe. 
Consolidation  and  fibrosis  upper  and  middle  lobes.  Infiltration 
left  upper  lobe.  Heart  displaced  to  right.  Diaphragm  elevated 
on  right.    No  glands  visible.    No  calcification.    (Class  III.) 

Case  XLVI. — L.,  adult,  male.  Large  cavity  in  right  upper 
lobe,  another  in  middle  lobe.  Consolidation  of  lower  lobe,  marked 
fibrosis  of  right  pleura.  Consolidation  left  upper  lobe.  Heart 
and  aorta  much  displaced  to  right.  Diaphragm  not  visible  on 
right.    No  glands  visible.    No  calcification  visible.    (Class  III.) 

Case  XL VII. — H.,  adult,  male.  Infiltration  right  apex.  Large 
pleural  effusion  on  left.  Heart  and  aorta  much  displaced  to  right. 
No  glands.  No  calcification.  Diaphragm  not  visible  on  left. 
(Class  II.) 

Case  XL VIII. — C,  adult,  male.  Infiltration  right  apex.  In- 
filtration, with  cavity,  left  upper  lobe.  Heart  normal  size  and 
position.  Diaphragm  normal.  No  glands.  No  calcification. 
(Class  III.) 

Case  XLIX. — P.,  adult,  female.  Consolidation  upper  right 
lobe  with  softening.  Infiltration  left  apex.  Heart  normal  size 
and  position.  Diaphragm  up  on  right.  No  glands.  No  calcifica- 
tion.   (Class  III.) 

Case  L. — M.,  adult,  female.  Cavity  right  apex,  consolidation 
right  upper  lobe  with  softening.  Infiltration  left  upper  lobe. 
Heart  normal  size  and  position.  Glands  enlarged.  Diaphragm 
elevated  on  right.    No  calcification.    (Class  III.) 

Case  LI. — M.,  adult,  male.  Infiltration  right  apex.  Con- 
solidation left  upper  lobe.  Heart  normal  size  and  position.  Glands 
enlarged.    Diaphragm  normal.    No  calcification.    (Class  II.) 

Case  LII. — A.,  adult,  male.  Large  cavity  right  upper  lobe, 
consolidation  and  marked  fibrosis  below.  Large  cavity  left  apex, 
consolidation  of  left  upper  lobe.  Heart  completely  displaced  to 
right.    Aorta   markedly   displaced.    Diaphragm    not   visible  on 


744 


FRANCINE:  TUBERCULOSIS 


ri^ht.  No  glands  visible.  Calcification  of  costal  cartilages  marked. 
(Class  III.) 

Case  LIII. — G.,  adult,  male.  Infiltration  both  apices.  Heart 
normal  size  and  position.  Glands  enlarged.  Diaphragm  elevated 
on  left.    No  calcification.    (Class  II.) 

Case  LIV. — Y.,  adult,  male.  Infiltration  right  apex.  Heart 
normal  size  and  position.  Glands  enlarged.  Diaphragm  normal. 
No  calcification.    (Class  I.) 

Case  LV. — M.,  adult,  male.  Infiltration  both  apices.  Heart 
normal  size  and  position.  Diaphragm  normal.  No  glands.  No 
calcification.    (Class  II.) 

Case  LVI. — E.,  adult,  male.  Disseminated  lesions  in  both 
upper  lobes,  marked  emphysema.  Heart  normal  in  position, 
enlarged  to  right.  Glands  enlarged.  Diaphragm  normal.  Cal- 
cification of  costal  cartilage.    (Class  II.) 

Case  LVII. — G,  adult,  male.  Infiltration  of  both  upper  lobes. 
Heart  normal  in  size  and  position.  Glands  enlarged.  Diaphragm 
normal.    Slight  calcification.    (Class  II.) 

Case  LVIII. — M.,  adult,  male.  Consolidation  right  upper 
lobe.  Infiltration  left  upper  lobe.  Heart  displaced  to  right. 
Enlarged  to  right.  Glands  enlarged.  Slight  calcification.  Dia- 
phragm elevated  on  right.    (Class  II.) 

Case  LIX. — L.,  adult,  male.  Large  cavities  right  upper  lobe, 
with  consolidation.  Marked  fibrosis  of  lungs  and  pleura,  righ. 
lower  lobe.  Cavity  left  apex,  with  consolidation  upper  lobet 
Heart  much  displaced  to  right.  Aorta  displaced  to  right.  Dia- 
phragm not  visible  on  right.  No  glands,  no  calcification  visible. 
(Class  III.) 

Case  LX. — J.,  adult,  female.  Infiltration  both  apices.  Heart 
normal  in  size  and  position.  Glands  enlarged.  Diaphragm 
normal.    No  calcification.    (Class  II.) 


REVIEWS. 


The  Principles  of  Pathology.  Vol.  I.  General  Pathology.  By 
J.  George  Adami,  M.D.,  LL.D.,  F.R.S.,  Professor  of  Pathology 
in  McGill  University,  Montreal.  Pp.  948;  322  engravings  and 
16  plates.  Vol.  II.  Systemic  Pathology.  By  J.  George  Adami 
and  Albert  G.  Nicholls,  M.A.,  M.D.,  D.Sc,  F.R.S.  (Can.), 
Assistant  Professor  of  Pathology  and  Lecturer  in  Clinical 
Medicine  in  McGill  University,  Montreal.  Pp.  1082;  310  engrav- 
ings and  15  plates.  Philadelphia  and  New  York:  Lea  &  Febiger, 
1909. 

Professor  Ad  a  mi's  Pathology  has  from  the  date  of  its  issue 
established  a  new  standard  for  similar  publications  in  America;  and 
has  lifted  whatever  opprobrium  may  have  been  fancied  in  the  often 
repeated  remark  that  there  has  been  no  American  pathology  (in  the 
sense,  of  course,  that  the  text-books  of  this  hemisphere  have  followed 
more  or  less  closely  the  thought,  plan,  and  substance  of  European, 
notably  German,  authorities). 

The  first  of  these  volumes,  now  in  the  second  year  after  publica- 
tion, has  been  widely  studied;  and  expectancy  has  changed  generally 
to  cordial  admiration  for  the  breadth  of  fundamental  discussion, 
the  mode  of  presentation,  and  the  clearness  of  expression  of  estab- 
lished knowledge,  as  well  as  for  many  of  the  personal  views  and 
applications  introduced  by  the  author.  There  have  been  numbers 
of  excellent  text-books  issued  from  American  presses  which  have 
not  failed  in  matter  of  systematization  of  the  subjects  and  in  descrip- 
tion of  pathological  processes  and  lesions;  but  in  the  endeavor  to 
set  cause  to  effect,  to  elucidate  the  rationale  of  events,  and  to  explain 
the  eternal  "how  and  why"  in  the  study  of  disease,  the  author's 
breadth  of  training  and  viewpoint,  as  well  as  his  experience  in  long 
years  of  teaching,  have  combined  to  make  the  work  notable. 

A  large  part  of  this  first  volume  is  essentially  preliminary,  devoted 
to  introductory  consideration  of  the  cell  as  a  unit  of  vital  organiza- 
tion, discussing  the  details  of  cellular  structure  and  interrelation  in 
complex  organisms,  our  knowledge  of  the  chemistry  and  physics 
of  cellular  activity,  growth,  multiplication,  adaptation,  and  differen- 
tiation, and  the  data  and  problems  of  reproduction  and  inheritance. 
The  essence  of  these  chapters  lies  in  the  author's  conception  of  the 
cellular  protein  molecules  as  elemental  structures,  biophores,  the 


746 


REVIEWS 


various  phenomena  of  energy  being  referred  to  changes  in  these; 
the  familiar  side-chain  theory  being  applied  in  explanation  of  their 
constitution  and  their  changes  in  metabolism.  This  same  idea  is 
followed  in  the  presentation  of  his  views  of  cellular  growth  and 
differentiation,  of  adaptation,  variation,  and  evolution,  as  well  as  the 
phenomena  of  inheritance.  The  more  recent  publication  of  Reichert 
and  Brown  upon  the  hemoglobins  of  the  animal  kingdom,  while 
not  directly  related,  will  be  found  to  lend  considerable  confirmation 
to  Adami's  view,  in  that  the  essence  of  distinction  in  evolution,  and 
probably,  too,  in  all  vital  phenomena,  whether  normal  or  pathological, 
must  be  carried  back  to  molecular  constitution.  Such  views  are 
rapidly  permeating  our  newer  conceptions  of  biology,  since  the 
development  of  physical  chemistry;  and  are  bound  in  the  near  future 
to  dominate  medicine,  just  as  in  the  past,  one  after  another,  the  cellular 
pathology  and  germ  theory  of  disease  bore  in  upon  us.  That  new 
cells  developing  from  the  original  fertilized  ovum  grow  by  side- 
chain  accretions  to  their  molecules;  come  to  differ,  as  slight  differences 
in  pabulum  in  diverse  locations  obtain;  and  progressively  diverge 
as  the  diverging  products  modify  more  and  more  the  side-chain 
construction  of  appropriating  molecules,  until  the  complete  cellular 
differentiation  of  the  body,  with  the  harmonious  interdependence  and 
mutual  resistance  of  its  cells,  is  established — this  is  basic.  The 
protoplasmic  molecule  of  one  cell  is  in  its  general  structure  like  the 
protoplasm  of  a  cell  of  a  different  organ,  or  like  a  cell  of  the  same 
part  from  a  different  animal;  and  the  differentiation  in  the  individual, 
or  the  evolutional  difference  in  different  species,  lies  mainly  in  the 
side-chains,  in  their  different  qualities,  valences,  and  affinities.  The 
chromosomic  theory  of  inheritance  has  never  been  entirely  satisfy- 
ing; but  one  can  with  Adami  see  under  it  in  the  possibilities  of  the 
chemical  interaction  of  the  complex  biophores  of  the  germ  cells,  a 
rational  explanation  for  the  dominance  of  one  parental  type,  the 
chance  for  variations  and  mutations,  and  can  see  a  reason  for  the 
only  certain  inheritance  of  acquired  characteristics  of  the  parents 
we  know,  that  which  follows  those  constitutional  and  toxic  influences 
which  may  fixedly  modify  the  molecular  constitution  of  the  germ 
cells,  and  in  turn  the  progeny  of  these  modified  cells. 

Thereafter,  after  discussion  of  antenatal  acquirement,  so  often 
confused  with  true  inheritance,  the  author  devotes  the  remainder 
of  the  first  part  of  the  volume  to  the  causes  of  postnatal  acquirement 
of  disease  and  the  pathological  processes  which  may  logically  be 
regarded  as  directly  reactive  or  responsive  to  these — inflammation 
as  a  local  reaction,  infection  with  its  general  response  in  pyrexia 
and  other  phenomena,  and  the  reactive  immunity  induced,  as  well 
as  syncope,  shock,  and  collapse  as  typifying  failure  of  or  negative 
reaction  (death,  however,  being  left  to  a  subsequent  section  in  the 
latter  part  of  the  volume).  Of  the  chapters  on  pathogenic  influences, 
including  those  of  mechanical,  physical,  chemical,  and  parasitic 


ad  ami:  the  principles  of  pathology 


747 


natures,  the  more  notable  are  devoted  to  the  endogenous  intoxi- 
cations from  internal  secretory  faults  and  faults  of  metabolism 
and  to  the  effects  of  overstrain  in  structural  and  physiological  sense, 
and  to  cellular  disuse. 

The  chapters  on  inflammation,  after  the  author's  well-known 
plan  of  considering  the  subject  in  a  comparative  manner  in  the 
simpler  organisms  leading  up  to  vertebrates  in  order  to  fix  the  essen- 
tial features  of  the  adaptive  reaction,  might  well  stand  as  a  type  of  the 
methods  pursued  throughout  the  volume.  Whatever  the  injury 
(and  the  author  takes  the  safe  ground  that  it  is  by  no  means  always 
of  microbic  origin),  the  two  prominent  factors  in  the  process  are  the 
proliferation  of  the  cells  about  the  injured  area  and  the  attraction 
of  the  wandering  cells  to  the  area,  the  role  of  the  bloodvessels  being 
strictly  secondary  in  that  it  really  but  facilitates  the  former.  One 
could  suggest  that  with  these  basic  factors  more  stress  might  be  laid 
upon  the  entrance  of  excess  of  the  body  fluid  into  the  area  with  its 
general  and  special  influences  toward  removal  of  the  cause  of  the 
process;  and,  too,  many  may  miss  in  this  luminous  discussion  a 
definitive  presentation  of  the  resolution  of  inflammation,  aside  from 
the  matter  of  repair  and  the  fate  of  the  leukocytes  and  fibrin,  for 
there  are  additional  problems  in  the  absorption  of  exudate  and 
liquid  waste,  in  the  resumption  of  vascular  tone  and  similar  features. 
Ehrlich's  side-chain  theory  is  basic  to  the  disquisition  upon  immunity; 
but  the  author  is  not  bound  rigidly  to  an  immediate  and  essential 
chemism  between  the  antigen  and  antibodies,  realizing  the  possi- 
bilities of  physical  relations  entering  into  the  problems  afforded  by 
the  recognized  phenomena  and  well  brought  forward  in  the  later 
trend  of  study. 

In  the  second  part  of  the  volume  the  familiar  progressive  and 
regressive  pathological  changes  of  less  definite  relation  or  of  unknown 
relation  to  cause  are  presented,  the  author  breaking  away  from 
the  common  habit  of  introducing  here,  however,  the  hyperemias, 
ischemia,  hemorrhage,  thrombosis,  embolism,  and  oedema,  reserving 
these  for  the  second  volume  in  connection  with  the  circulatory 
system.  The  line  of  discussion  includes  in  the  first  group  hyper- 
trophy, regeneration,  transplantation,  metaplasia  and  the  neoplasms; 
in  the  second,  the  atrophies,  abioplasia,  reversions,  degenerations  and 
infiltrations,  necroses,  and  somatic  death.  In  the  descriptive  part  of 
each  clearness  and  sufficiency,  as  may  be  expected,  prevail;  but,  as  in 
the  first  part  of  the  volume,  the  notable  features  lie  in  the  analysis  of 
cause  and  relation  and  in  the  presentation,  where  this  is  impossible, 
of  reasonable  working  theory.  It  is  an  open  question  as  to  the  value 
of  adding  to  existing  morphological  or  relative  classifications  of  the 
tumors;  if  it  be  granted,  there  are  points  of  excellence  in  the  author's 
separation  of  neoplasms  into  those  of  the  lining  (lepidoma)  and 
those  of  the  pulp  tissues  (hyloma),  although  it  removes  none  of  the 
difficulties  in  routine  employment  of  Cohnheim's  basic  arrangement. 


748 


REVIEWS 


Whatever  the  cause  of  a  tumor,  Adami  would  hold  there  is  assumed 
a  peculiarity  in  its  elements,  not  so  much  shown  morphologically 
as  in  the  predominance  of  a  vegetative  over  the  ordinary  functionating 
character  of  the  cell.  Why  such  a  character  is  assumed  may  be  a 
matter  of  hypothesis,  but  there  is  reason  to  suppose  that  just  as 
mutations  in  animals  and  plants  are  not  mere  chance,  but  determined 
more  or  less  by  alterations  in  environment,  so  it  may  be  thought 
possible  that  cellular  mutations  of  the  type  in  question  may  by  a 
variety  of  internal  somatic  conditions  be  determined,  and  there  is  no 
reason  that  stimuli  of  external  origin,  bacterial,  chemical,  or  physi- 
cal, may  not  do  the  same.  He  would  look  to  no  specific  cause  for 
tumors  and  seek  for  no  parasite  as  definitely  neoformans.  The 
tumor  cell  itself  is  a  modified  body  cell,  and  in  its  modification  is  the 
specific  element  (itself  the  antigen)  and  working  out,  the  more 
atypical  it  is,  its  own  antibodies  from  the  somatic  reaction  to  itself. 
Gaylord's  work  showing  the  development  of  immunizing  substances 
in  mice  recovering  from  certain  tumors,  that  of  Jensen  in  inducing 
disappearance  of  tumor  growth  in  mice  by  injecting  into  the 
animals  the  elements  of  a  part  of  the  tumor  itself,  as  well  as  that  of 
Coca  along  similar  lines,  and  the  recent  announcement  by  Hodenpyl 
of  a  curative  material  for  human  cancer  shown  in  the  ascitic  fluid 
of  a  cancerous  human  being,  and  other  work  of  the  same  type, 
are  all  leading  to  a  similar  conclusion;  and  it  is  a  safe  prediction 
by  the  author  that  ultimate  triumph  over  these  growths  is  far  from 
hopeless. 

In  the  second  volume,  Prof.  A.  G.  Nicholls  collaborates  with 
Adami.  The  association  is  valuable,  no  doubt,  in  a  number  of 
ways,  but  at  the  same  time  it  leads  to  occasional  lack  of  perfect 
harmony  between  the  products  of  the  two  authors,  the  senior  writer 
commonly  presenting  for  each  section  an  introductory  portion 
dealing  with  the  broad  pathological  problems  in  structure  and 
physiological  relation,  and  the  junior  author  assuming  the  details 
of  gross  and  minute  anatomical  description.  Systemic  pathology 
for  its  greater  attractiveness  should  be  presented  in  as  fully  applied 
form  as  possible,  with  frequent  indication  of  the  relation  of  the  exist- 
ing anatomical  lesion  with  the  symptoms  manifested  by  the  living 
subject,  and  with  the  distinct  purpose  of  correlating  with  the  primary 
lesions  the  secondary  and  complicating  faults  which  invariably 
arise  and,  as  a  rule,  prove  in  their  combination  the  cause  of  death 
rather  than  the  isolated  primary  lesion.  Herein  the  authors  are 
hampered  by  lack  of  space ;  and  the  fault  in  mind  is  not  a  qualitative 
but  rather  a  quantitative  one.  It  may  be  remedied  in  future  editions 
by  fuller  discussion  of  the  functional  effects  of  at  least  the  more 
important  types  of  lesions,  giving  to  classes  of  students  a  more  certain 
habit  of  reasoning  from  a  pathological  basis  in  their  clinical  studies 
and  at  the  same  time  insuring  a  more  ready  application  of  patho- 
logical knowledge  by  the  practitioner.    There  is  little  reason  for  an 


long:  a  text-book  op  physiological  chemistry  749 


elaborate  description  of  this  second  volume,  which  follows  through 
the  diseases  of  the  blood,  cardiovascular  and  hemopoietic  organs, 
respiratory  and  other  systems  of  the  body  in  regular  order,  each  with 
excellent  anatomical  exposition  of  its  important  lesions  and  with 
sections  upon  the  broader  pathological  physiology  of  each,  which 
are  as  valuable  from  the  infrequency  of  such  discussions  in  works 
on  pathology  as  from  their  intrinsic  excellence. 

If,  as  Professor  Adami  says  in  his  preface,  the  book  was  twelve 
years  in  its  forming,  it  is  worth  all  the  time  and  the  effort.  It  cannot, 
of  course,  remain  indefinitely  fresh:  there  is  too  rapid  progress  for 
such  expectation.  But  it  has  been  shaped  along  lines  which  are 
permanent  or  at  least  look  far  into  the  future;  and  is  certain  for  its 
many  excellences  to  be  long-lived  by  repeated  revision  without  actual 
recasting.  A.  J.  S. 


A  Text  Book  of  Physiological  Chemistry  for  Students 
of  Medicine.  By  John  H.  Long,  M.S.,  Sc.D.  Second 
edition.    Philadelphia:  P.  Blakiston's  Son  &  Co.,  1909. 

The  subject  matter  of  Dr.  Long's  book  is  divided  into  four  sec- 
tions: I.  The  Nutrients;  II.  Ferments  and  Digestive  Processes; 
III.  The  Chemistry  of  the  Blood,  the  Tissues,  and  Secretions  of  the 
Body,  and  IV.  The  End  Products  of  Metabolism.  In  this  edition 
a  few  changes  have  been  made,  notably  the  adoption  of  the  protein 
classification  recommended  by  American  biological  chemists,  and  a 
new  chapter  on  the  methods  used  in  urine  analysis. 

One  is  rather  appalled  at  the  outset  by  being  confronted  with  a 
sentence  containing  134  words,  of  such  involved  construction  and 
of  such  obscure  meaning  that  if  asked  what  he  read,  one  might  well 
reply  with  Hamlet,  "Words,  words,  words!"  The  entire  book  while 
not  guilty  again  of  such  verbosity,  is  nevertheless  quite  beyond  the 
understanding  of  the  medical  student.  Unless  he  is  exceptionally 
well  grounded  in  organic  chemistry  the  book  in  many  parts  is  incom- 
prehensible, and  the  undergraduate  who  can  read  Chapters  III  and 
IV  with  an  intelligent  grasp  of  the  subject  is  the  fortunate  possessor 
of  unusual  training  and  intellect.  Chapter  XIV,  dealing  with  the 
complicated  theme  of  special  properties  of  blood  serum,  reflects  great 
credit  on  the  author.  Dr.  Long  has  presented  this  subject  in  a 
clear,  concise,  and  easily  understood  manner,  and  the  only  adverse 
criticism  that  might  be  raised  is  that  the  author  would  have  made 
his  topic  more  clear  had  diagrammatic  illustrations  been  shown. 
The  chapter  devoted  to  urinary  examinations  is  hardly  complete 
enough  in  detail  for  one  to  make  even  practical  metabolic  studies, 
and  the  index  is  very  unsatisfactory.  As  a  text-book  the  work  is 
too  lacking  in  explanation,  and  we  fear  the  student  will  be  unneces- 
sarily confused  by  the  at  best  recondite  subject.  As  a  laboratory 
book  used  in  conjunction  with  practical  demonstrations  and  intelli- 
gent instruction  it  may  find  a  field  of  usefulness.  E.  H.  G. 

vol.  139,  no.  5. — may,  1910.  25 


750 


REVIEWS 


Chemical  and  Microscopical  Diagnosis.  By  Francis  Carter 
Wood,  M.D.,  Professor  of  Chemical  Pathology  in  the  College 
of  Physicians  and  Surgeons,  Columbia  University,  New  York. 
Second  edition;  pp.  725;  192  illustrations.  New  York  and 
London:  D.  Appleton  &  Company,  1909. 

This  book,  which  comprises  about  the  best  of  our  knowledge  on 
the  subject,  is  a  noteworthy  addition  to  laboratory  literature.  It 
describes,  for  the  most  part,  in  good  working  detail,  the  examination 
of  the  blood,  gastric  contents,  feces,  parasites,  oral  and  nasal  secre- 
tions, sputum,  urine,  transudates  and  exudates,  and  milk.  Some 
of  the  methods  as  given  are  lacking  in  essential  points  of  description, 
and  certain  well-known  tests  have  failed  to  find  a  place  in  the  work 
under  discussion.  The  author  has  chosen  to  give  the  reference 
where  a  new  method  was  first  published,  and  this  would  seem 
advisable  in  all  laboratory  manuals,  since  it  is  apparently  impossible 
to  find  accurate  record  of  technique  in  books  of  this  nature.  The 
plates  and  illustrations  are  uniformly  good,  and  it  is  a  rather  novel 
experience  to  make  new  acquaintances  in  the  pictorial  line,  instead 
of  meeting,  as  has  been  the  reviewer's  misfortune  in  the  past,  one's 
old  friends  reproduced  in  book  after  book.  Dr.  Wood's  second 
edition  is  to  be  heartily  recommended;  ^hose  engaged  in  laboratory 
practice  will  find  it  a  most  useful  addition  to  an  already  long  list  of 
laboratory  books.  E.  H.  G. 


Lehrbuch  der  klinischen  Diagnostik  innerer  Krankheiten. 
Edited  by  Paul  Krause,  M.D.,  Professor  and  Director  of  the 
Medical  Polyclinic  in  Bonn,  Germany.  Pp.  922;  360  illustra- 
tions.   Jena:  Gustav  Fischer,  1909. 

The  Text-book  of  the  Clinical  Diagnosis  of  Internal  Diseases, 
edited  by  Professor  Krause  is  the  composite  work  of  thirteen  colla- 
borators. Professor  Krause  himself  contributes  chapters  on  the 
methods  of  examining  patients,  on  x-ray  examinations,  and  on 
clinical  bacteriology;  Professor  Wandel,  of  Kiel,  discusses  the 
anamnesis  and  the  general  habitus  of  the  patient,  and  the  diagnosis 
of  the  acute  infectious  disease;  Professor  Lommel,  of  Jena,  diseases 
of  the  upper  air  passages  and  exploratory  puncture  and  cytology; 
Professor  Gerhardt,  of  Basle,  diseases  of  the  respiratory  apparatus; 
Professor  Staehelin,  of  Berlin,  diseases  of  metabolism,  and  in  associa- 
tion with  Professor  Ortner,  of  Innsbruck,  diseases  of  the  circulatory 
apparatus;  Professor  Winternitz,  of  Halle,  diseases  of  the  urogenital 
tract;  Professor  Ziegler,  of  Breslau,  diseases  of  the  blood;  Professor 
Mohr,  of  Halle,  diseases  of  the  digestive  tract;  Professor  Jamin,  of 
Erlangen,  and  Professor  Finklenburg,  of  Bonn,  diseases  of  the 


HERBERT!  CATARACT  EXTRACTION 


751 


nervous  system;  Professor  Hertel,  of  Jena,  diseases  of  the  eye  in 
internal  diseases;  and  Professor  Esser,  of  Bonn,  diseases  of  infants. 
The  book  is  well  written,  and  sufficiently  comprehensive,  since 
although  it  includes  about  all  that  is  necessary  there  is  little  if  any 
mention  of  etiological  factors  and  of  matters  of  doubtful  moment. 
It  may  be  said  to  be  representative  of  the  present  German  school  of 
medicine,  and  as  such  is  to  be  highly  commended.  A.  K. 


Cataract  Extraction.  By  H.  Herbert,  F.R.C.S.,  Late  Lieu- 
tenant-Colonel, I. M.S.,  Professor  of  Ophthalmic  Medicine  and 
Surgery  in  the  Grant  Medical  College,  and  in  charge  of  the 
Sir  Cowasjee  Jehangir  Ophthalmic  Hospital,  Bombay.  Pp.  391. 
New  York:  William  Wood  &  Co.,  1908. 

This  work  is  equally  valuable  for  its  abundant  citations  from 
the  writings  of  others  who  have  treated  of  the  same  subject  and  for 
the  fruitful  lessons  the  author  has  drawn  from  his  own  experience, 
comprising  as  it  does  about  5000  extractions;  and  even  this  number 
he  declares  to  be  small  compared  with  the  work  of  other  ophthalmic 
surgeons  in  India.  The  writer  tells  us  that  grave  conjunctival 
disease  is  much  more  common  in  India  than  in  Europe  or  America. 
This  unfavorable  condition  has  to  be  dealt  with  speedily  and 
efficiently;  abundant  douching  with  bichloride  solution,  1  to  3000, 
is  the  mainstay  and  has  yielded  the  most  satisfactory  results — indeed, 
so  satisfactory  that  evil  is  turned  to  good;  the  douchings  being 
rarely  necessary  in  the  western  world,  they  are  omitted  in  the  occa- 
sional cases  where  they  would  prevent  infection.  Of  1655  extrac- 
tions, not  a  single  suppuration  occurred,  certainly  justifying  the 
author's  claim  of  a  near  approach  to  perfection  in  this  respect.  We 
confess  to  some  surprise,  however,  at  the  statement  that  nasal  infection 
through  the  lacrimal  passages  does  not  take  place.  The  chapter 
descriptive  of  the  operation,  which  takes  up  nearly  one-half  of  the 
whole  book,  is  very  thorough  even  to  minuteness.  The  combined 
operation  is  considered  to  be  the  standard.  The  capsule  is  divided 
vertically  with  the  cystitome  and  the  delivery  of  the  lens  is  aided  by 
fixation  forceps,  differently  applied  in  accordance  with  special 
indications.  Irrigation  is  employed  when  necessary  to  remove 
blood,  etc.  Chapter  IV  deals  with  "variations  in  procedure,"  the 
most  valuable  portion  of  which  is  the  critical  appreciation  of  the 
merits  and  faults  of  methods  other  than  the  writer's.  There  is 
necessarily  considerable  repetition  here,  but  this  is  hardly  a  fault 
for  the  serious  student. 

In  a  work  so  meritorious  as  this  one,  for  which  the  entire  oph- 
thalmic world  will  be  sincerely  grateful,  it  seems  ungracious  to  seek 


752 


REVIEWS 


out  any  shortcomings.  While  we  rise  from  perusal  of  the  book 
instructed  as  from  no  other  with  which  we  are  acquainted  upon  the 
subject  of  modern  methods  for  operating  upon  cataract,  we  have  a 
feeling  that  the  subject  is  presented  somewhat  obscurely  and  that 
the  reader  fails  to  get  as  clear  an  idea  of  the  whole  as  the  excellent 
matter  deserves.  A  little  greater  attention  to  method  will  easily 
overcome  what  is  a  fault  of  form  but  not  of  substance.  T.  B.  S. 


A  Text-book  of  Diseases  of  the  Ear.  By  Macleod  Years- 
ley,  F.R.C.S.,  Senior  Surgeon  to  the  Royal  Ear  Hospital, 
London.  Pp.  452.  Chicago  Medical  Book  Co.,  Chicago,  111., 
1909. 

This  book  is,  as  is  stated  in  the  preface,  an  expansion  of  a  previous 
work  of  the  author  on  Common  Diseases  of  the  Ear,  but  it  is 
really  an  entirely  new  publication,  and  in  its  present  form  is  justly 
entitled  to  rank  as  a  very  complete  text-book  of  otology.  In  the 
arrangement,  it  follows  the  customary  classification  of  the  various 
subjects,  although  there  are  two  useful  chapters  included  on  some- 
what unusual  lines,  namely,  Chapter  XII,  on  the  "The  Influence  of 
General  Diseases  of  the  Ear,"  and  Chapter  XV  on  "The  Medico- 
legal and  Life  Assurance  Aspects  of  Otology."  The  book  is 
thoroughly  up  to  date  in  its  consideration  of  all  the  most  recent 
developments  in  the  science  of  otology.  There  is  an  excellent, 
though  brief,  account  of  the  recent  advances  in  our  knowledge  of 
the  physiological  and  pathological  conditions  of  the  labyrinth.  The 
various  operations  upon  the  temporal  bone  are  well  described,  and 
the  subject  of  the  intracranial  complications  of  aural  disease  is 
excellently  considered.  Like  most  English  otologists,  the  author 
adopts  Lake's  classification  of  the  results  of  tests  for  bone  and 
air  conduction  by  Rhine's  method,  using  Greek  letters  as  symbols 
for  the  test.  To  most  American  aurists,  such  a  classification  simply 
serves  to  complicate,  and,  as  a  rule,  they  prefer  writing  out  the  test 
result  in  full,  to  the  use  of  an  arbitrary  symbol.  The  illustrations 
throughout  the  book  are  generally  original,  and  of  most  excellent 
quality.  It  can  be  safely  commended  to  the  student  of  otology  as 
an  excellent  epitome  of  the  subject.  F.  R.  P. 


PROGRESS 

OF 

MEDICAL  SCIENCE. 


MEDICINE. 


UNDER  THE  CHARGE  OF 

WILLIAM  OSLER,  M.D., 

REGIUS  PROFESSOR  OF  MEDICINE,  OXFORD  UNIVERSITY,  ENGLAND, 
AND 

W.  S.  THAYER,  M.D., 

PROFESSOR  OF  CLINICAL  MEDICINE,  JOHNS  HOPKINS  UNIVERSITY,  BALTIMORE,  MARYLAND 


The  Effect  of  Digitalis  on  the  Ventricular  Rate  in  Man. — Of  the  cardiac 
irregularities  produced  experimentally  by  digitalis,  the  earliest  to  appear 
is  usually  an  occasional  omission  of  ventricular  contractions,  owing  to 
the  blocking  of  the  stimulus  from  auricle  to  ventricles.  A  somewhat 
late  phenomenon  is  the  production  of  a  complete  auriculoventricular 
dissociation  which  differs  from  ordinary  heart-block  in  that  the  ven- 
tricular rate  is  not  slow,  but  approaches,  and  usually  exceeds  that  of  the 
auricles.  Although  a  common  result  of  digitalis  poisoning  in  dogs, 
this  condition  has  never  been  noted  in  man  except  in  the  case  reported 
by  Hewlett  and  Barringer  (Arch.  Int.  Med.,  1910,  v,  93).  Their 
patient,  a  man,  aged  twenty-seven  years,  with  chronic  myocardial  in- 
sufficiency, who  had  taken  digitalis  in  moderate  doses  over  a  considerable 
length  of  time,  developed  on  the  day  before  his  death,  a  remarkable 
condition.  Tracings  of  the  venous  pulse  and  apex  showed  a  regularly 
recurring  cycle  of  changes  apparently  depending  on  the  interference 
of  two  systems  of  waves  which  were  independent  of  each  other,  and  not 
quite  synchronous.  Each  cycle  lasted  about  seven  seconds  and  included 
fourteen  ventricular  contractions.  The  two  systems  of  waves  were 
evidently  due  to  the  auricular  and  ventricular  contractions,  and  the 
rates  were  such  that  for  thirteen  auricular  there  were  fourteen  ventricular 
contractions.  Hewlett  and  Barringer  believe  this  to  be  the  result  of 
a  cumulative  action  of  the  digitalis,  and  call  attention  to  the  fact  that 
it  may  be  difficult  to  ascertain  when  enough  of  the  drug  has  been  given, 
for  at  no  time  was  there  a  slowing  of  the  pulse.  While  in  experimental 
heart-block  the  rate  of  the  ventricle  is  increased  by  digitalis,  there  is 
little  clinical  evidence  on  the  subject.    In  a  case  of  complete  heart- 


754 


PROGRESS  OF  MEDICAL  SCIENCE 


block  with  slow  pulse,  however,  the  same  writers  failed  to  note  any 
increase  of  ventricular  rate  after  the  use  of  moderately  large  doses  of 
digitalis.  It  is  possible  that  the  appearance  of  extrasystoles  and  the 
temporary  disappearance  of  the  a  waves  from  the  jugular  pulse  (due 
to  a  toxic  weakening  of  the  auricular  contractions?)  may  have  been 
due  to  the  drug. 

Auricular  Fibrillation. — It  is  well  known  that  in  the  latest  stages  of 
cardiovascular  degeneration,  especially  in  mitral  stenosis,  the  pulse  often 
becomes  exceedingly  irregular,  and  in  the  jugular  the  wave  of  auricular 
contraction  disappears.  This  has  long  been  regarded,  particularly  by 
Mackenzie,  as  depending  upon  the  origin  of  the  rhythm  at  the  node  of 
Tawara  (hence  the  term  nodal  rhythm).  Lewis  {Brit.  Med.  Jour., 
1909,  ii)  asserts  that  facts  are  at  his  disposal  permitting  the  conclusion 
that  the  rhythm  arising  in  the  neighborhood  of  node  gives  rise  to  a  differ- 
ent clinical  picture.  This  conclusion  is  based  upon  the  study  of  an  in- 
stance of  paroxysmal  tachycardia  in  which  auricle  and  ventricle  contract 
together.  Secondly,  the  pulsus  irregularis  perpetuus  is  dependent  upon 
fibrillation  of  the  auricle.  This  conclusion  is  based  upon  the  fact  that 
the  rhythm  is  exactly  similar  to  that  which  may  be  produced  experi- 
mentally by  inducing  fibrillation  of  the  auricle,  and  is  a  unique  condi- 
tion. Lewis  points  to  the  fact  that  electrocardiograms  taken  from 
patients  exhibiting  this  irregularity,  show  a  number  of  irregular  waves 
apart  from  the  ventricular  curve,  and  more  clearly  defined  in  diastole. 
Such  waves  are  found  in  no  other  disorder  of  the  heart  action.  They 
disappear  when  irregularity  vanishes,  are  not  evident  upon  the  cardio- 
gram, and  are  identical  with  the  curves  yielded  by  fibrillation  of  the 
auricle.  Furthermore,  synchronous  tracings  show  that  the  waves  in 
the  experimental  cardiogram  correspond  to  the  fibrillary  movements 
of  the  auricle.  [In  connection  with  this  interesting  communication 
it  may  be  remembered  that  Cushny  and  Edwards  in  the  American 
Journal  of  the  Medical  Sciences,  1907,  cxxxiii,  66,  arrive  at  the 
conclusion  that  an  instance  of  paroxysmal  irregularity  was  probably 
due  to  this  cause.— W.  S.  T.] 

The  Etiology  of  Eeri-beri. — The  studies  of  Fraser  and  Stanton  at 
the  Institute  for  Medical  Research,  Federated  Malay  States  {Trans. 
Soc.  Tropical  Med.  and  Hygiene,\9l0,  iii,  257),  are  based  on  the  chemical 
analyses  of  various  types  of  rice,  and  on  the  production  of  polyneuritis 
gallinarum,  a  disease  analogous  to  beri-beri,  by  feeding  experiments 
in  fowls.  It  was  first  found  that  Siam  rice,  which  is  most  often  associ- 
ated with  epidemics  of  beri-beri,  contains  a  lower  percentage  of  fat, 
than  either  Rangoon  rice  or  parboiled  rice.  Microscopic  sections 
showed  that  in  Siam  rice  the  pericarp,  the  outer  layer,  containing  nost 
of  the  aleurone  and  oily  material,  had  been  removed  by  the  proc^.i:  of 
polishing.  The  relation  of  the  milling  of  rice  to  the  production  of  the 
disease  in  fowls  was  then  studied.  Fowls  fed  on  the  original  padi  ale 
remained  healthy.  Of  twelve  fowls  fed  on  the  finished,  polished  rice, 
six  developed  polyneuritis.  Other  fowls  fed  on  the  same  finished  rice, 
plus  the  polishings,  all  remained  healthy.  From  these  experiments 
Fraser  and  Stanton  concluded  that  the  polishing  of  white  rice  removes 
from  the  seed  some  substance  essential  to  the  maintenance  of  the 


Medicine 


755 


normal  nutrition  of  nerve  tissues.  It  was  further  shown  that  staleness 
of  rice,  or  the  development  in  it  of  poisonous  substances  subsequent 
to  its  being  milled  are  not  important  factors.  Parboiled  rice,  in  itself 
healthy,  when  extracted  with  alcohol,  caused  polyneuritis  in  fowls, 
but  the  addition  of  the  alcoholic  extract  to  a  rice  known  to  be  injurious 
prevented  this  disease.  Further  chemical  investigations  showed  that 
the  power  of  a  rice  to  produce  polyneuritis  gallinarum  varied  with  its 
phosphorus  content — the  higher  the  phosphorus  content,  the  less  liable 
was  it  to  be  injurious.  The  highest  percentage  of  phosphorus  was 
found  to  be  present  in  rice  polishings.  Moreover,  the  addition  to  an 
injurious  rice  of  a  quantity  of  polishings  which  contained  enough  phos- 
phorus to  bring  the  total  phosphorus  content  up  to  that  of  parboiled 
rice  sufficed  to  preserve  nutritive  equilibrium.  The  prevention  of 
beri-beri  thus  depends  on  the  substitution  of  ordinary  white  rice,  by 
a  rice  in  which  the  polishing  process  has  been  omitted,  or  carried  out 
to  a  minimal  extent,  or  by  the  addition  to  a  white  rice  diet  of  articles 
rich  in  those  substances  which  are  not  present  in  sufficient  amount  in 
white  rice.  One  such  article,  which  is  cheap,  and  may  be  readily  ob- 
tained, is  the  polishings  from  white  rice. 

The  Physiology  of  the  Immediate  Reaction  of  Anaphylaxis. — On  the 

injection  of  a  dose  of  horse  serum  into  the  vein  of  a  previously  highly 
sensitive  guinea-pig,  there  occurs  a  chain  of  symptoms — chiefly  of 
respiratory  nature,  which  result  in  the  death  of  the  animal  in  from  three 
to  five  minutes.  While  the  general  type  of  the  reaction  has  been  re- 
ported and  confirmed  by  various  observers,  it  has  remained  for  Auer 
and  Lewis  {Jour.  Exper.  Med.,  1910,  xii,  151)  to  study  and  explain 
the  physiological  basis.  While  convulsive  and  paralytic  symptoms  may 
dominate  the  picture  if  the  animal  is  loose,  they  found  that  if  it  is  held 
in  a  suitable  holder  these  are  less  marked  and  the  respiratory  changes 
come  into  the  foreground.  They  thus  paid  especial  attention  to  the 
lungs,  and  found,  as  did  Gay  and  Southard,  that  at  autopsy  the  lung 
in  acute  anaphylaxis  tends  to  remain  in  an  inspiratory,  distended  con- 
dition with  open  thorax,  with  unobstructed  trachea,  and  large  bronchi, 
and  without  obvious  pulmonary  oedema.  This  immobilization  of  the 
lungs  they  consider  to  be  the  most  characteristic  sign  of  immediate 
anaphylaxis  in  the  guinea-pig.  Experiments  were  performed  in  which 
the  respiratory  movements  of  the  chest  and  the  volume  changes  of  the 
pleural  cavity  were  recorded,  as  well  as  others  in  which  the  animals 
were  allowed  to  breathe  from  a  bottle,  and  changes  during  inspiration 
and  expiration  registered.  As  a  result  it  was  evident  that  some  stenosis 
is  gradually  produced  in  the  pulmonary  passages  so  that  in  the  final 
stage  practically  no  air  enters  or  leaves  the  lung  in  spite  fof  violent 
respiratory  attempts.  Death  is  due  to  asphyxia.  The  characteristic 
reaction  of  anaphylaxis  was  also  obtained  in  pithed  animals,  showing 
that  its  production  depends  on  a  peripheral  process  in  the  lung,  and 
not  on  the  central  nervous  system.  After  reviewing  the  possible  cause 
of  the  condition,  the  authors  conclude  that  it  is  due  to  a  tetanic  contract- 
ion of  the  muscles  of  the  finer  bronchioles,  so  that  air  is  imprisoned  in 
the  areolar  sacs.  Atropine,  which  paralyzes  the  bronchial  muscles, 
may,  under  certain  conditions,  be  able  to  relax  the  anaphylactic  lung 
so  that  it  is  again  able  to  expand  and  contract.    The  blood  pressure 


756 


PROGRESS  OF  MEDICAL  SCIENCE 


in  immediate  anaphylaxis  first  shows  a  considerable  rise,  and  then  a 
gradual  drop  to  10  to  20  mm.  Shortly  after  the  injection  of  the  toxic 
dose,  a  heart  block,  often  with  a  3  to  1  rhythm,  develops,  and  is  probably 
due  to  asphyxia.  The  cardiac  vagus  gradually  loses  its  irritability  after 
injection  of  the  toxic  dose. 

Jaundice  in  Pneumonia. — As  a  result  of  the  experimental  study  of 
cholecystitis,  Lemierre  and  Abrami  have  previously  shown  the  impor- 
tant part  played  by  descending,  hematogeneous  infections  in  the  pro- 
duction of  inflammation  of  the  bile  passages.  They  now  (La  presse 
med.,  1910,  No.  10,  82)  report  three  fatal  cases  of  pneumonia  associated 
with  jaundice  in  which  bacteriological  examination  of  the  bile  at  autopsy 
showed  pure  cultures  of  pneumococcus.  In  all  three  instances  the  stools 
were  colorless,  but  careful  search  revealed  no  obstruction  in  the  bile 
passages.  The  fluid  in  the  gall-bladder  was  nearly  colorless,  and  in 
two  of  the  cases  failed  to  give  a  Gmelin  reaction.  They  believe  that 
the  primary  cause  of  the  jaundice  is  an  involvement  of  the  liver  paren- 
chyma, and  that  any  inflammation  of  the  bile  ducts  is  purely  secondary. 
In  all  of  the  cases  there  were  signs  of  alcoholic  cirrhosis  of  the  liver,  and 
Lemierre  and  Abrami  consider  that  hepatitis  complicating  pneumonia 
is  rare  except  when  the  liver  has  been  the  seat  of  some  previous  patho- 
logical process. 


On  the  Quantity  of  Glycuronic  Acid  in  the  Urine  in  Health  and  Disease. — 

Tollens  and  Stern  (Hoppe-Seijlers  Ztschr.  f.  physiol.  Chemie,  1910, 
lxiv,  39)  have  found,  by  means  of  a  new  quantitative  method  recently 
described  by  Tollens,  that  the  excretion  of  glycuronic  acid  in  the  urine 
is  far  greater  than  has  generally  been  supposed.  Mayer  and  Neuberg, 
for  example,  give  the  daily  average  output  as  0.004  gm.  per  100  c.c., 
whereas  the  authors  find  0.025  gm.  per  100  c.c.  or  0.3  to  0.4  gm.  in  the 
twenty-four  hours'  urine  as  the  average  in  health.  In  several  cases  of 
diabetic  coma,  they  have  encountered  a  complete  absence  of  glycuronates 
in  the  urine,  tested  with  the  naphthoresorcin  test.  Administration  of 
sodium  salicylate,  which  causes  a  marked  augmentation  of  the  glycuro- 
nates in  the  urine  as  a  rule,  failed  to  produce  a  positive  reaction  in  these 
cases.  Various  drugs,  especially  salicylates  and  chloral  hydrate, 
combine  with  glycuronic  acid  in  the  body;  after  their  administration, 
the  glycuronic  acid  may  amount  to  1.4  gm.  per  diem.  In  one  case  of 
carbolic  acid  poisoning  (25  gm.  ?  taken)  the  urine,  blackish  green  in 
color  and  definitely  levorotatory,  contained  8.5  gm.  of  glycuronic  acid 
on  the  first  day.  Such  a  urine,  of  course,  is  capable  of  reducing  Fehling's 
solution. 


The  Cultivation  of  the  Organism  of  Infantile  Paralysis. — It  is  of  interest 
in  relation  to  the  recent  publications  of  Flexner  and  Lewis  on  the  etio- 
logical factor  of  anterior  poliomyelitis,  to  receive  the  results  reported 
by  Levaditi  (Presse  medicale,  1910,  No.  6,  44)  in  a  preliminary  note 
from  the  Pasteur  Institute.  In  several  experiments  he  has  inoculated 
bouillon  to  which  the  blood  serum  of  monkeys  and  rabbits  has  been  added, 
with  active  filtrates  containing  the  specific  organism.  In  one  instance  the 
medium  became  cloudy  after  being  kept  in  the  themostat  for  ten  days. 
At  the  end  of  fifteen  days  the  culture  was  injected  into  a  monkey.  After 


MEDICINE 


757 


an  incubation  period  of  twenty  days  paralysis  set  in,  thus  demonstrating 
that  the  organism  retains  its  virulence  for  at  least  fifteen  days  at  38 
degrees.  Microscopic  examination  of  the  cloudy  medium  by  ordinary 
methods  showed  no  micro-organisms,  but  after  centrifuging,  dissolving 
the  clot  and  mordanting  after  fixation  by  alcohol  or  heat,  he  was  able  to 
find  a  large  number  of  round  or  rather  oval  bodies,  appearing  in  pairs  or 
in  masses.  They  are  extremely  small  and  are  sometimes  polymorphous. 
They  do  not  stain  well  with  aniline  dyes,  but  after  prolonged  staining 
with  dilate  fuchsin  assume  a  pale  pink  color,  or  appear  as  clear  dots 
surrounding  by  a  pinkish  zone.  Control  experiments  with  culture 
media  which  had  not  been  inoculated  showed  only  granules  of  quite 
different  size  and  shape. 

Rat-bite  Fever. — Horder  {Quarterly  Jour,  of  Med.,  1910,  iii,  121) 
has  collected  three  instances  of  an  apparently  specific  kind  of  blood- 
poisoning  following  the  bite  of  a  rat.  The  most  prominent  symptom 
noted  was  periodic  fever  beginning  from  twenty-one  to  twenty-eight 
days  after  the  occurrence  of  the  bite.  The  temperature  rose  to  103°  to 
104°,  fell  to  normal  in  two  to  three  days,  and  then  rose  again  in  the  course 
of  the  next  few  days.  In  one  case  the  remission  continued  over  several 
months.  During  the  febrile  periods  there  was  a  well  marked  leuko- 
cytosis. In  two  instances  there  was  a  blotchy  erythema,  and  in  one  of 
these  indurated  plaques  and  diffuse  tender  subcutaneous  nodules  were 
present.  Blood  cultures  and  the  inoculation  of  blood  into  animals  gave 
no  results  and  the  examination  of  stained  specimens  of  blood  failed  to 
reveal  any  parasites.  There  was  no  enlargement  of  the  spleen.  The 
prolonged  incubation  period,  the  form  of  the  fever  and  the  absence  of 
suppuration  in  the  original  wound  make  it  unlikely  that  the  cause  of  the 
disease  is  a  pyogenic  infection  secondary  to  the  bite.  Horder  considers 
that  the  etiological  factor  is  probably  a  protozoon.  [It  is  interesting  to 
note  that  Quincke  {Mitt.  aus.  d.  Grenzgebeit,  d.  tried,  u.  Chir.,  1900,  v, 
231)  has  reported  eleven  cases  of  almost  exactly  the  same  symptom-com- 
plex which  occurred  in  Japan.  He  also  refers  to  a  number  of  articles  in 
the  Japanese  literature,  and  states  that  while  there  is  no  mention  of  it  in 
European  literature,  a  characteristic  remittent  febrile  disease  following 
the  bite  of  a  rat  after  a  more  or  less  prolonged  incubation  period,  has 
been  recognized  in  Japan  for  many  years. — W.  S.  T.] 

"Nail-palpation"  of  the  Arterial  Wall. — Wertheim-Salomonson 
{Deut.  Arch.  f.  klin.  Med.,  1910,  xcviii,  596)  calls  attention  to  the  well- 
known  difficulties  of  palpating  the  arterial  wall  (1)  where  the  arterial 
wall  is  thin,  (2)  when  it  is  densely  covered  with  fat,  and  (3)  when 
the  blood  pressure  is  high.  He  proposes  a  method,  which  he  calls 
"nail-palpation"  (Nagelpalpation),  by  means  of  which  any  arterial 
wall,  whether  it  can  be  palpated  in  the  usual  way  or  not,  may  be  felt, 
and  its  thickness  fairly  well  judged.  Instead  of  palpating  the  artery 
with  the  ball  of  the  finger,  the  finger-nail  is  used.  The  nail  is  placed 
perpendicularly  on  the  surface  of  the  skin,  so  that  the  edge  of  the  nail 
runs  parallel  with  the  long  axis  of  the  artery.  By  moving  the  finger 
transversely  across  the  artery,  the  latter  slips  under  the  nail  as  if  it  were 
dissected  out.  The  artery  may  be  palpated  in  this  way  almost  as  readily 
in  young  children  as  in  adults.    With  a  little  practice,  Wertheim- 


758 


PROGRESS  OF  MEDICAL  SCIENCE 


Salomonson  says  one  quickly  learns  to  recognize  arterial  thickening. 
The  method  is  applicable  to  the  palpation  of  any  artery  which  rests 
on  a  firm  bed,  as  well  as  to  the  palpation  of  many  superficial  nerves. 

A  Previously  Undescribed  Symptom  of  Tetany. — H.  Schlesinger 
(Wien.  klin.  Woch.,  1910,  xxiii,  315)  has  observed  a  new  sign  in  a  typical 
case  of  tetany,  which  he  designates  the  ''Beinphanomen.''  The  sign 
is  elicited  in  the  following  manner:  If  one  seizes  the  leg  with  the  knee 
joint  extended  and  then  flexes  the  thigh  on  the  abdomen,  in  a  short  time 
(at  the  most,  two  minutes)  an  extensor  cramp  develops  in  the  knee 
with  extreme  supination  of  the  foot.  The  phenomenon  may  appear 
when  the  patient  sits  up  in  bed.  If  the  trunk  is  flexed  on  the  thighs,  the 
spasm  likewise  appears.  Like  the  Trousseau  phenomenon,  the  new 
sign  can  be  brought  out  in  the  intervals  between  attacks.  The  fre- 
quency of  occurrence  of  the  Beinphanomen  in  tetany  cannot  be  foretold 
as  yet;  nor  is  it  known  that  the  sign  is  one  peculiar  to  tetany. 


SURGERY. 


UNDER  THE  CHARGE  OF 

J.  WILLIAM  WHITE,  M.D., 

JOHN  RHEA  BARTON   PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  J 
SURGEON  TO  THE  UNIVERSITY  HOSPITAL, 
AND 

T.  TURNER  THOMAS,  M.D., 

ASSOCIATE  IN  SURGERY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA;  SURGEON  TO  THE  PHILADEL- 
PHIA GENERAL  HOSPITAL,  AND  ASSISTANT  SURGEON  TO  THE   UNIVERSITY  HOSPITAL. 


Atlo-axoid  Fracture  Dislocation—  Pilch er  (Annals  of  Surgery,  1910, 
li,  208)  reports  a  case  which  has  been  under  his  care  for  a  period  of 
nearly  ten  years,  and  therefore  represents  the  possibilities  of  ultimate 
repair  and  restoration  of  function  which  may  take  place  in  such  cases. 
The  patient,  a  man,  aged  thirty-three  years,  fell  headlong  a  distance  of 
fifteen  feet,  striking  on  his  forehead.  His  head  was  notably  bent  over 
toward  his  left  shoulder  and  was  fixed  in  such  great  flexion  that  he 
could  not  open  his  mouth  more  than  a  half-inch.  He  had  no  symptoms 
other  than  suboccipital  pain  and  the  deformity  and  stiffening  of  the  neck. 
During  the  following  two  months  he  was  conscious  of  a  growing  lack 
of  power  in  his  lower  limbs,  most  marked  on  the  right  side.  Shortly 
afterward  it  was  found  that  he  had  no  power  in  his  right  arm  or  leg, 
except  a  little  in  the  fingers  and  toes.  Catheterization  became  neces- 
sary. Pilcher  saw  him  first  about  three  months  after  the  injury,  and 
six  weeks  later  the  atlas  and  axis  were  exposed  by  operation.  A  for- 
ward dislocation  of  the  atlas  upon  the  axis  was  demonstrated,  but  care- 
ful attempts  to  reduce  it  were  futile  and  the  wound  was  closed.  A  slight 
improvement  developed  in  the  subsequent  weeks.  He  became  able  to 
empty  his  bladder  spontaneously  and  two  months  after  the  operation 


SURGERY 


759 


began  to  sit  up.  He  was  still  hemiplegic  when  he  left  the  hospital  ten 
weeks  after  the  operation.  A  gradual  return  of  power  in  the  para- 
lyzed leg  manifested  itself  after  his  return  home  and  continued  until 
the  normal  condition  returned.  Less  improvement  occurred  in  the  right 
upper  extremity.  Nine  years  after  the  accident  the  deformity  of  the 
head  and  neck  and  the  immobility  were  unchanged.  He  is  able  to 
walk  normally  fairly  long  distances  without  fatigue.  There  is  no  diff- 
erences in  strength  between  the  two  lower  limbs.  The  bladder  func- 
tion is  normal  and  his  mentality  is  unaffected. 

Malignant  Degeneration  of  Benign  Diseases  of  the  Breast. — Speese 
(Annals  of  Surgery,  1910,  li,  212)  follows  Warren's  classification.  He 
finds  that  certain  tumors  which  present  symptoms  of  malignancy  do 
not  show  malignant  histological  changes,  and,  on  the  other  hand, 
carcinoma  occasionally  arises  in  a  preexisting  tumor  without  causing 
symptoms  indicative  of  such  a  transformation.  It  is  conlcuded  that 
operative  interference  in  all  tumors  of  the  fibroepithelial  type,  is  in- 
dicated to  prevent  this  complication.  Two  instances  of  carcinomatous 
changes  were  found  in  17  cases  of  periductal  fibroma  studied  patho- 
logically. In  both  there  were  one  or  two  symptoms  which  were  only 
suggestive  of  cancer.  Abnormal  involution  (chronic  mastitis)  occurs 
more  frequently  than  any  other  affection  of  the  breast  with  the  exception 
of  carcinoma.  In  180  cases  of  breast  disease,  Speese  found  it  in  18 
per  cent.,  and  of  the  35  cases  studied  in  the  laboratory,  9  instances  of 
malignancy  were  encountered  (26  per  cent.).  In  295  cases  of  abnormal 
involution  reported  by  9  different  writers  44  were  found  to  be  carcino- 
matous (15  per  cent.).  In  doubtful  cases  exploratory  incision  is  in- 
dicated; a  careful  search  throughout  the  entire  part  involved  is  necessary, 
for  the  malignant  area  is  apt  to  be  small.  Malignancy  being  detected, 
a  radical  operation  should  be  performed.  The  exploratory  incision 
does  not  reduce  in  any  way  the  chance  of  ultimate  cure,  whereas  explora- 
tory incision  followed  by  the  radical  operation  for  malignancy  at  a  later 
period  has  been  invariably  fatal  according  to  Bloodgood.  The  bilateral 
character  of  the  disease  is  one  of  the  interesting  features  and  one  for 
which  occasional  double  amputation  has  to  be  performed.  Cystadeno- 
mas,  cancer  cysts  and  mastitis  are  also  discussed.  Areas  of  indura- 
tion following  mastitis  should  receive  as  careful  attention  as  other  forms 
of  benign  disease,  early  removal  of  which  may  remove  its  greater  danger. 

The  Treatment  of  Cystitis,  Especially,  Severe  Postoperative  Cases. — 

Schlafi  (Zeit.  f.  Gyn.  u.  Urol.,  1910,  ii,  4)  says  that  in  most  cases  he 
has  not  used  irrigations  but  has  depended  chiefly  upon  internal  therapy, 
with  flushing  and  disinfection  from  within.  For  urinary  antiseptics 
he  has  employed  aspirin,  benzosalin,  novaspirin,  and  diplosal.  Of  these 
the  most  effective  was  aspirin.  When  irrigations  were  employed  the 
quantity  injected  was  never  so  great  that  it  distended  and  irritated  the 
bladder  walls.  It  was  given  slowly  and  regularly  and  the  temperature  of 
the  fluid  was  usually  between  18°  and  20°  C.  Only  somewhat  persistent 
acute  and  subacute  catarrhal  conditions  and  especially  severe  pus 
cases,  make  irrigation  necessary.  Aniodol  was  found  to  be  the  best 
antiseptic  solution  for  the  irrigation.  It  is  a  formaldehyde  preparation 
with  some  sulphozyanallyl.    Its  bactericidal  properties  are  greater  than 


760 


PROGRESS  OF  MEDICAL  SCIENCE 


that  of  other  urinary  antiseptics.  According  to  Fouard's  investigations 
it  can  be  said  that  it  gives  the  greatest  therapeutic  effect  with  the  least 
danger,  since  it  is  neither  caustic  nor  toxic  like  sublimate  and  car- 
bolic acid.  Schlafi  used  it  in  a  0.25  per  cent,  solution,  which  gave  it 
a  sufficient  concentration  and  produced  no  symptoms  of  irritation. 
It  has  simplified  the  treatment  of  cystitis.  It  provides  for  the  mechan- 
ical cleansing,  and  the  removal  of  the  decomposed  urine  and  its  con- 
tained pus;  and  it  provides  the  best  bactericidal  effect  without  the  dis- 
advantages of  other  equally  strong  disinfectants. 


The  Operative  Treatment  of  Wounds  of  the  Lungs. — Moller  (Archiv 
f.  hlin.  Chir.,  1909,  xci,  295)  says  that  up  to  a  few  years  ago  penetrating 
wounds  of  the  thorax  involving  the  lungs,  were  generally  treated  con- 
servatively, with  rest  in  bed,  morphine,  ice,  and  antiseptic  treatment  of 
the  wound.  A  simple  occlusive  dressing,  or  incision  and  tampon 
of  the  wound  in  the  thoracic  wall  or  suture  of  the  wound  was  employed. 
For  some  years  efforts  have  been  made  to  find  the  lung  wound,  through 
a  sufficient  opening  in  the  chest  wall,  and  tosuture  or  tampon  the  wounded 
lung  surface.  Stucky  reported  25  cases  of  wounds  of  the  lungs  treated 
by  suture,  and  concluded  that  in  every  stab  wound  of  the  thorax  coming 
into  the  hospital  within  twenty-four  hours  after  the  accident,  the  ribs 
should  be  resected,  the  lung  wound  exposed  and  sutured.  This  led 
to  the  collection  and  study  of  similar  cases  from  Korte's  clinic,  from 
which  it  was  determined  that  the  radical  operation  proposed  by  Stucky, 
not  only  was  not  necessary,  but  was  improper;  and  that  these  wounds 
healed  with  simple  occlusive  dressing.  In  some  few  severe  cases  free 
exposure  and  direct  treatment  of  the  lung  were  justified.  The  material 
studied  consisted  of  90  cases  in  which  the  pleura  and  perhaps  the  lung 
were  wounded,  48  by  gun-shot,  19  by  stab  or  incision,  and  in  23  there 
was  a  subcutaneous  laceration  of  the  lung,  12  wTith  and  11  without  a 
fracture  of  the  ribs  or  sternum.  Of  the  48  gun-shot  cases,  the  symp- 
toms occurred  as  follows:  Hemothorax,  37  times;  hemoptysis,  21  times; 
pneumothorax,  12  times;  and  connective  tissue  emphysema,  9  times. 
The  treatment  and  course  were  as  follows:  Puncture  and  aspiration, 
10  times;  empyema,  4  times;  rib  resection,  twice;  excision  of  the  shot, 
14  times.  Death  resulted  in  7,  and  the  average  duration  of  healing 
was  five  to  five  and  one-half  weeks.  The  following  complications 
occurred:  Wound  of  the  pericardium  in  5,  of  the  heart  in  2,  of  the  dia- 
phragm and  abdominal  organs  in  2,  and  of  the  spinal  canal  in  1.  Of 
the  19  stab  wound  cases,  the  prominent  symptoms  occurred  as  follows: 
Hemothorax  in  9,  hemoptysis  in  3,  pneumothorax  in  7,  and  emphysema 
in  8.  Puncture  and  aspiration  were  employed  in  2,  and  the  average 
time  of  healing  was  three  and  one-half  to  four  weeks.  Wound  of  the 
pericardium  occurred  in  2  cases.  Of  the  23  cases  in  which  subcutaneous 
rupture  of  the  lung  occurred  without  wound  of  the  thoracic  wall,  the 
symptoms  were  as  follows :  Hemothorax  in  3,  hemoptysis  in  4,  pneumo- 
thorax in  1,  and  emphysema  in  8.  Death  occurred  in  7,  and  the  average 
time  of  healing  was  four  weeks.  The  complications  were:  Fracture  of 
the  skull  in  1,  rupture  of  the  liver  in  1,  and  wTound  of  the  kidney  and 
hematuria  in  1.  Of  the  7  deaths  in  the  67  penetrating  wounds,  in  only 
2,  or  at  most  3,  cases,  was  the  question  of  operation  presented.  Of 
Stuckey's  25  stab  wounds,  all  of  which  were  operated  on,  death  occurred 


SURGERY 


761 


in  9,  abscess  of  the  lung  or  empyema  in  12,  and  the  average  time  of 
healing  was  ten  weeks.  In  Moller's  19  stab  wounds  which  penetrated 
the  lung,  none  died,  in  none  was  there  suppuration,  and  the  average 
time  of  healing  was  three  and  one-half  to  four  weeks.  Moller  gives 
the  indications  for  operation  as  follows:  Severe  primary  hemorrhage; 
continuing  and  repeated  hemorrhage;  severe  pneumothorax  and  emphy- 
sema; and  secondary  pneumothorax.  With  the  observance  of  these 
indications,  the  prognosis  of  these  cases  in  the  future  should  be  somewhat 
better  than  they  have  been  up  to  the  present  with  conservative  treatment. 

Stasis  Hemorrhages  Resulting  from  Compression  of  the  Thorax  and 
Abdomen. — Koch  and  Ronne  (Archiv  f.  klin.  Chir.,  1909,  xcl,  371) 
reports  a  case  in  which  a  man  was  severely  compressed  in  an  elevator 
accident.  Immediately  after  the  accident  his  appearance  was  alarming. 
His  head  and  neck  were  very  cyanotic,  of  a  dark  blue,  almost  black,  color, 
and  he  had  small  and  large  petechial  hemorrhages  under  the  skin 
everywhere.  The  head  was  swollen  out  of  shape  and  the  breathing 
was  almost  imperceptible.  The  skin  of  the  neck  projected  over  the 
collar  of  the  clothing,  the  eyes  protruded,  and  there  were  subconjunc- 
tival hemorrhages.  In  striking  contrast  to  these  phenomena  was  the 
slight  effect  on  the  general  condition.  Very  often  these  patients  are 
completely  conscious  during  the  whole  period  of  the  compression  of  the 
chest  and  abdomen.  The  cyanosis  disappears  in  a  few  days,  the  small 
hemorrhages  somewhat  later,  the  subconjunctival  hemorrhages  remain- 
ing perhaps  several  weeks.  If  no  complicating  lesions  are  present, 
in  a  few  days  the  patients  probably  feel  sound.  In  58  collected  cases, 
in  only  7  did  the  complications  produce  a  fatal  result.  The  most  prob- 
able explanation  of  the  phenomena  is  that  with  a  closed  glottis  the 
blood  of  the  lungs  and  heart  is  forced  into  the  peripheral  vessels.  The 
cyanosis  is  very  marked  in  the  head  and  neck  and  very  rare  in  the  ex- 
tremities, because  the  jugular  veins  have  no  valves.  They  are  occasion- 
ally insufficient  in  the  axillary,  but  are  very  resistant  in  the  veins  of 
the  lower  extremities.  Disturbances  of  sight  are  common,  often  with- 
out demonstrable  cause  ophthalmoscopically.  They  were  present  in 
11  (12  with  the  case  here  reported)  out  of  the  58  cases.  Occasionally 
there  is  a  brief  double  blindness,  which  lasts  for  some  minutes  or  a 
half  hour.  In  other  cases  sight  does  not  return  or  does  so  only  incom- 
pletely, and  after  some  time  an  atrophic  discoloration  of  the  papillse 
develops  showing  that  the  nerve  fibers  have  become  degenerated. 


An  Experimental  and  Literary  Study  Concerning  the  Manner  and  Path- 
way of  Extension  of  Urogenital  Tuberculosis. — Sawamura  (Dent.  Zeit. 
Chir.,  1910,  ciii,  203)  in  investigating  the  method  of  extension,  assumes 
that  in  primary  urogenital  tuberculosis,  the  process  begins  in  the  kidney 
and  extends  through  the  ureter  to  the  bladder  and  prostatic  urethra, 
and  through  the  vas  deferens  to  the  testicle.  It  may  begin  in  the  testicle 
and  extend  in  the  reverse  direction,  or  beginning  in  the  seminal  vesicles, 
it  may  extend  in  both  directions  to  the  testicles  and  kidneys.  Upon 
the  basis  of  the  literature  it  is  agreed  that  the  process  often  begins 
in  the  kidney  and  that  the  bladder  may,  in  time,  be  infected,  although 
a  sound  mucous  membrane  can,  to  a  certain  extent,  protect  the  bladder. 
Tubercle  bacilli  in  the  bladder,  usually,  will  not  infect  the  kidney,  if 


762 


PROGRESS  OP  MEDICAL  SCIENCE 


the  normal  stream  of  urine  is  not  obstructed,  but  will  do  so  in  the  pres- 
ence of  such  obstruction.  When  tubercle  bacilli  are  injected  into  the 
ureter,  especially,  into  the  renal  pelvis,  tuberculosis  of  the  kidney  can 
be  produced,  with  or  without  ligation  of  the  ureter,  although  the  latter 
undoubtedly  favors  its  development.  The  infection  must  pass  by  the 
blood,  lymph,  or  ureter.  The  blood  path  is  excluded  from  considera- 
tion because  by  it  is  produced  usually  a  general  tuberculosis.  Sawamura 
carried  out  experiments  on  dogs  to  determine  the  path  of  extension. 
He  failed  to  find  that  the  tubercle  bacilli  ascended  from  the  bladder 
through  the  ureter  to  the  kidney.  By  direct  injection  of  the  bacilli 
into  the  lumen  of  the  ureter,  without  subsequent  occlusion  of  the  ureter, 
a  renal  tuberculosis  was  produced.  Extending  by  the  lymph  paths 
to  the  kidney,  vesical  or  genital  tuberculosis  rarely  invades  the  kidney. 
It  may  ascend  from  the  bladder  to  the  kidney  without  obstruction  of 
the  blood  stream,  when  from  contraction  of  the  bladder  a  relatively 
high  internal  pressure  is  produced  and  in  any  manner  an  antiperistaltic 
movement  of  the  ureter  occurs.  Tuberculous  involvement  of  the  lower 
end  of  the  ureter  may  produce  the  necessary  obstruction,  stagnation, 
and  dilatation,  to  permit  the  tubercle  bacilli  to  reach  the  kidney.  That 
the  process  may  ascend  by  the  lymph  paths  cannot  be  denied,  although 
it  has  never  been  established  in  men  or  animals  with  certainty.  Tuber- 
culosis of  the  testicle  or  epididymis,  as  a  rule,  extends  through  the  vas 
deferens  toward  the  urethra.  More  rarely  it  may  extend  by  the  lymph 
vessels.  It  may  remain  localized  in  the  testicle  and  epididymis.  Often 
the  vas  is  involved.  The  lymph  vessels  of  the  testicle  go  chiefly  to  the 
nodes  along  the  inferior  cava,  near  the  entrance  of  the  spermatic  vein; 
those  from  the  epididymis  to  the  nodes  along  the  hypogastric  vessels. 
The  central  (lying  next  the  urethra)  portion  of  the  vas  deferens,  may 
become  infected  from  tubercle  bacilli  in  the  urine.  Tuberculous 
epididymitis  can  develop  from  tubercle  bacilli  in  the  urine  by  way  of 
the  vas  deferens,  provided  the  orifice  of  the  vas  or  its  lumen  is  blocked, 
so  that  with  the  stagnation  of  the  secretion  and  exudate,  the  tubercle 
bacilli  are  transported  to  the  epididymis.  Extension  from  a  tuber- 
culous epididymis,  without  participation  of  the  vas  deferens,  did  not 
occur  in  Sawamura' s  experiments,  although  Oppenheim,  and  Law  and 
Hausen  considered  this  possible.  A  primary  focus  of  tuberculosis 
can  develop  in  the  prostrate.  It  may  involve  the  seminal  vesicles  and 
it  is  assumed,  therefore,  that  it  may  extend  to  the  epididymis.  The 
seminal  vesicles  may  be  involved  alone.  Sawamura  believes  that  in 
dogs  an  ascending  tuberculosis  of  the  female  genitals  can  occur. 

The  Treatment  of  Bone  and  Joint  Tuberculosis  by  the  X-rays. — Iselin 
{Dent.  Zeit.  f.  Chir.,  1910,  ciii,  483)  had  already  obtained  excellent 
results  in  the  treatment  of  tuberculosis  of  glands  and  other  soft  tissues. 
Two  years  ago,  at  the  request  of  his  chief,  Prof.  Wilms,  he  undertook 
the  same  treatment  of  the  bones  and  joints.  In  all,  41  cases  were 
treated,  including  the  bones  and  joints  of  the  hand,  foot,  elbow, 
knee,  sacro-iliac  joint,  and  ribs.  The  method  was  as  follows:  In  the 
beginning  of  the  treatment,  the  bone  or  joint  was  exposed  to  the  x-rays, 
three  or  four  times  at  short  intervals,  every  exposure  being  made  from 
a  different  side  and  always  with  the  fullest  dose,  until  all  parts  had  been 
exposed.    The  rays  were  passed  through  an  aluminum  plate,  1  mm. 


THERAPEUTICS 


763 


thick.  Because  the  effects  on  the  skin  did  not  show  until  two  or  three 
weeks,  the  exposures  were  made  only  every  three  or  four  weeks.  More 
than  three  such  exposures  were  unnecessary.  From  the  beginning  the 
joints  were  placed  in  a  position  favorable  for  cicatricial  contraction, 
except  in  the  case  of  the  small  joints.  If  the  tuberculosis  healed  by 
cicatrization,  after  treatment  was  necessary  to  reproduce  the  mobility. 
This  consisted  of  exposures  to  hot  air,  massage  of  the  joints,  and  move- 
ments. This  kind  of  healing  was  obtained  in  10  cases  of  bone  and  joint 
tuberculosis.  Almost  always  the  progress  was  visible,  and  was  obtained 
in  many  otherwise  hopeless  cases.  The  method  is  not  suited  to  children, 
because  the  epiphyseal  cartilage  can  be  damaged,  and  in  the  large  joints 
of  adults,  as  the  shoulder  and  hip,  the  x-rays  could  not  be  made  to  pene- 
trate deep  enough. 


THERAPEUTICS. 


UNDER  THE  CHARGE  OF 

SAMUEL  W.  LAMBERT,  M.D., 

PROFESSOR    OF    APPLIED   THERAPEUTICS    IN  THE    COLLEGE  OF    PHYSICIANS    AND  SURGEONS, 
COLUMBIA  UNIVERSITY,  NEW  YORK. 


Diet  in  Typhoid  Fever. — Coleman  (Jour.  Aimer.  Med.  Assoc.,  1909, 
liii,  1145)  advocates  a  more  liberal  diet  in  the  treatment  of  typhoid 
fever.  He  says  that  the  average  milk  diet  of  two  quarts  daily  supplies 
an  insufficient  l umber  of  calories  to  provide  for  the  increased  needs  of 
the  body.  Consequently  patients  on  a  milk  diet  lose  weight  and  strength 
and  are  less  able  to  cope  with  the  disease  than  patients  on  a  more  liberal 
diet.  Coleman  advises,  as  the  minimum  requirement,  a  diet  containing 
the  equivalent  of  41  calories  per  kilo  of  body  weight.  Thus,  a  man 
weighing  one  hundred  and  fifty  pounds  will  receive  during  the  twenty- 
four  hours  a  diet  equivalent  to  3000  calories.  Coleman  and  Shaffer 
found  that  the  best  results  were  obtained  when  the  diets  furnished  60 
to  80  calories  per  kilo.  In  all  instances,  the  patients  on  a  liberal  diet 
were  brighter  and  stronger  and  better  able  to  fight  the  disease.  The 
principal  constituents  of  Coleman's  diet  are  milk,  cream,  milk  sugar, 
and  eggs.  In  addition,  small  slices  of  stale  bread  or  toast,  with  as  much 
butter  as  the  patient  wished,  were  allowed.  He  gave  to  his  cases 
one  and  one-half  quarts  of  milk,  from  one  to  two  pints  of  cream,  from  one- 
half  to  one  and  two-thirds  pounds  of  milk  sugar,  and  from  three  to  six 
eggs.  Coleman  says  that  he  has  seen  no  bad  effects  from  the  use  of 
milk  in  moderate  amounts,  and  he  does  not  believe  that  it  increases  the 
tendency  to  tympanites.  A  quart  of  good  milk  is  equivalent  to  about 
740  calories.  Coleman  furnishes  the  bulk  of  the  fat  in  his  diet;  by 
means  of  cream.  It  is  not  advisable  to  give  more  than  one-third  of 
the  total  calories  in  the  form  of  fat.  A  pint  of  cream  contains  about 
1300  calories.  Some  of  the  patients  were  able  to  take  as  much  as  two 
pints  of  cream,  but  when  the  larger  quantities  cause  diarrhoea  the  amount 
of  cream  in  the  diet  must  be  diminished.    Carbohydrates  protect  body 


764 


PROGRESS  OF  MEDICAL  SCIENCE 


protein  better  than  any  other  foodstuff.  For  this  reason  Coleman 
supplies  a  large  quantity  of  the  energy  of  his  diet  in  that  form. 
Starches  cannot  be  used  in  quantity  because  of  their  bulk  and  the  con- 
sequent tax  on  the  digestive  organs.  He  prefers  milk  sugar  because  it 
is  not  very  sweet  and  not  so  likely  to  disgust  the  taste  as  other  sugars, 
and  because  it  does  not  so  readily  produce  digestive  disturbances.  The 
objections  to  its  use  are  that  in  some  patients  it  produces  nausea  and 
vomiting,  but  more  often  vomiting  without  nausea.  When  vomiting 
occurs,  the  milk  sugar  should  be  stopped.  In  a  few  cases  milk 
sugar  caused  tympanites,  but  usually  the  patients  could  be  gradually 
taught  to  take  and  assimilate  large  amounts.  An  ounce  of  milk  sugar 
is  equivalent  to  120  calories.  Milk  sugar  may  be  given  in  the  milk;  in 
coffee,  tea,  or  coca,  in  lemonade,  or  in  custard  made  with  milk  and  egg. 
Coleman  and  Shaffer  found  that  in  order  to  maintain  nitrogen  equi- 
librium from  12  to  16  gm.  of  nitrogen  are  required  in  the  diet.  Approxi- 
mately 11  gm.  are  contained  in  one  and  one-half  quarts  of  milk  and 
one  pint  of  cream.  Coleman  supplies  the  deficiency  in  nitrogen  with 
eggs.  A  two-ounce  egg  will  supply  1  +  gm.  nitrogen.  The  details 
of  administering  the  diet  may  be  modified  to  suit  the  individual  case. 
Coleman  gives  as  a  working  basis  six  ounces  of  milk  with  two  ounces 
of  cream  every  two  hours.  From  one  to  four  tablespoonfuls  of  milk 
sugar  are  added  to  the  milk  and  cream  mixture.  The  eggs  may  be  given 
soft-boiled,  poached,  or  raw  in  milk  with  or  without  whiskey. 


Antidiphtheritic  Sarum  and  Antidiphtheritic  Globulin  Solutions. — Park 

{Jour.  Amer.  Med.  Assoc.,  1910,  liv,  251)  says  that  until  recently  the  only 
means  of  giving  diphtheria  antitoxin  was  in  the  whole  serum  of  the 
horse  in  which  it  had  originated.  Lately  a  practical  method  has  been 
developed  to  eliminate  a  portion  of  the  non-antitoxic  serum  substances 
while  retaining  the  antitoxin.  Park  gives  a  brief  description  of  two 
globulin  preparations  containing  diphtheria  antitoxin.  He  also  points 
out  the  fact  that  the  blood  serum  from  different  horses  varies  not  only 
in  antitoxic  potency,  but  also  in  its  liability  to  produce  disagreeable  after- 
effects. Thus,  different  lots  of  serum  of  the  same  manufacturer  will 
vary  in  liability  to  produce  rashes,  and  this,  together  with  the  idiosyn- 
crasy of  the  patient,  causes  some  physicians  to  approve  and  others  to 
condemn  the  preparations  of  the  same  manufacturers.  Park  compares 
the  effects  of  antidiphtheritic  serum  with  those  obtained  by  the  globulin 
preparations.  He  believes  that  the  globulin  preparations  contain  all  the 
important  substances  of  the  whole  antidiphtheritic  serum.  He  also  states 
that  the  rashes  and  after-effects,  in  cases  observed  by  him,  were  un- 
doubtedly much  less  after  the  Gibson  injections  than  after  the  whole 
serum,  and  somewhat  less  after  the  injections  of  the  Banzhaf  modifi- 
cation than  after  that  of  Gibson.  Curiously  enough,  only  certain  types 
of  rashes  are  eliminated.  The  urticarial  reactions  still  frequently 
follow. 


Tuberculin  Treatment  of  Tuberculosis. — Lowenstein  ( Therap.  Monats., 
1909,  xi,  593)  used  Koch's  "old"  tuberculin  in  the  treatment  of  300  cases 
of  open  pulmonary  tuberculosis  at  the  Beelitz  sanatorium.  He  com- 
mences with  a  dose  of  0.0002  gm.,  being  convinced  that  smaller  doses 
are  liable  to  induce  anaphylaxis.    In  case  of  a  strong  general  reaction 


THERAPEUTICS 


765 


with  focal  phenomena,  he  waits  fourteen  or  eighteen  days  before 
resuming  the  treatment.  After  a  milder  reaction  he  waits  seven  to 
ten  days.  When  the  doses  of  tuberculin  have  reached  0.1  gm.,  the 
intervals  between  injections  should  be  at  least  ten  days.  He  does  not 
reduce  the  dose  after  a  reaction,  but  increases  it  more  or  less  according 
to  the  intensity  of  the  reaction.  Lowenstein  terminates  the  treatment 
when  the  patients  can  stand  0.5  gm.  without  reaction.  In  order  to 
avoid  a  considerable  general  or  local  reaction,  Koch's  "bacillen  emul- 
sion" is  given  instead  of  the  "old"  tuberculin.  Lowenstein  advocates 
the  use  of  tuberculin  in  every  case  in  which  the  physician  thinks 
improvement  is  possible.  He  says  he  has  used  tuberculin  in  1000  cases, 
and  has  never  observed  a  dangerous  hemorrhage  that  could  be  ascribed 
to  the  influence  of  the  tuberculin  injections.  He  gives  as  contra-indica- 
tions  to  the  use  of  tuberculin,  persistent  headache,  pointing  to  the  locali- 
zation of  the  infection  in  the  central  nervous  system,  nephritis,  unless  of 
tuberculous  origin,  diabetes,  epilepsy,  and  pregnancy. 

The  Treatment  of  Gastrcptcsis. — Von  Nookden  (Therapie  d.  Gegen- 
wart,  1910,  i,  1)  believes  that  the  chief  indication  in  the  treatment  of 
gastroptosis  is  to  improve  the  nutrition  of  the  patient.  The  falling  of 
the  stomach  is  not  only  a  result  of  stomach  atony,  but  is  also  due  to  the 
lack  of  support  from  thin  and  relaxed  abdominal  walls.  The  stomach 
must  never  be  overloaded,  and  he  advises  small  and  frequent  meals  of 
high  nutritive  value.  Solid  and  fluid  food  should  not  be  taken  at  the 
same  time.  He  advises  as  an  important  part  of  the  treatment  that  the 
patient  should  lie  down  after  the  principal  meals,  with  the  body  turned 
slightly  toward  the  right  side.  Von  Noorden  thinks  that  strychnine 
phy.sostigmine,  and  pilocarpine  increase  the  tone  of  the  atonic  stomach. 
He  has  seen  no  benefit  derived  from  wearing  abdominal  binders  as 
regards  the  position  of  the  stomach,  which  he  determined  by  the  Ront- 
gen  rays.  However,  a  binder  frequently  adds  to  the  general  comfort 
of  the  patient  and  is  of  use  especially  in  nervous  patients. 

The  Treatment  of  Gastric  Disease  with  Aluminum  Silicate.— Rosenheim 
and  Ehrmann  (Deutsch.  med.  Woch.,  1910,  hi,  111)  report  their  observa- 
tions regarding  the  action  of  aluminum  silicate  in  gastric  affections 
especially  those  dependent  upon  a  stimulated  secretion.  They  say  that 
in  all  cases  of  hyperacidity  or  hypersecretion  of  neurotic  origin,  or  asso- 
ciated with  organic  disease,  aluminum  silicate  acts  most  favorably  in 
reducing  the  acidity,  quieting  the  pain,  and  aiding  digestion.  Alumi- 
num silicate,  as  prepared  by  Kahlbaum  under  the  name  neutralon,  is 
a  fine,  tasteless,  and  odorless  powder  insoluble  in  water.  An  ideal 
remedy,  they  say,  should  have  the  power  to  bind  the  excessive  hydro- 
chloric acid  in  a  harmless  combination,  and  also  should  have  a  protec- 
tive and  an  astringent  effect  upon  the  mucous  membrane.  They  claim 
that  aluminum  silicate  has  these  advantages.  When  taken  into  the 
stomach  it  is  broken  up  by  the  hydrochloric  acid  forming  silicic  acid 
and  aluminum  chloride.  They  state  that  aluminum  chloride  has  a 
protective  and  astringent  effect  upon  the  gastric  mucous  membrane 
similar  to  that  of  silver  nitrate  and  bismuth,  without  the  disadvantage 
of  a  possible  toxic  action.  Furthermore,  silver  nitrate  at  times  causes 
diarrhoea,  and  bismuth  is  constipating.    They  gave  aluminum  silicate 


766 


PROGRESS  OF  MEDICAL  SCIENCE 


in  doses  of  from  one-half  to  one  teaspoonful  in  about  three  ounces 
of  water  one-half  to  one  hour  before  meals.  There  were  no  untoward 
symptoms  from  its  use.  Theoretically  they  attribute  an  intestinal 
antiseptic  action  to  the  aluminu  ■  chloride  and  are  endeavoring  to 
determine  this  by  further  observations. 

Substitutes  for  Digitalis— Mendel  {Med.  Klin.,  1909,  xli,  1551) 
says  that  the  full  benefit  of  digitalis  can  only  be  obt  ined  from  prepara- 
tions containing  the  mixed  glucosides  of  digitalis.  Since  the  mixed 
glucosides  are  responsible  for  the  gastro-intestinal  irritation,  the  only 
sure  way  we  have  of  avoiding  them  is  to  give  the  drug  intravenously. 
Digitalin,  digitoxin,  and  digalen  do  not  contain  the  mixed  glucosides,  and 
consequently  Mendel  has  given  up  their  use.  He  speaks  very  highly 
of  digitalone,  which  is  prepared  from  the  fresh  leaves  and  accurately 
standardized.  Mendel  has  given  digitalone  to  more  than  200  patients, 
and  has  never  seen  any  cumulative  action  or  other  untoward  effects. 
The  effect  of  a  single  dose  is  not  so  marked  as  that  of  digalen  or  stro- 
phanthin,  but  Mendel  believes  it  is  infinitely  safer.  Strophanthin  and 
digalen  are  dangerous  because  of  the  tendency  to  an  overstimulation, 
with  consequent  depression  of  the  heart.  Mendel  has  seen  a  large 
number  of  patients  with  marked  cardiac  insufficiency,  who  because  of 
their  inability  to  take  digitalis  i  iternally  were  kept  alive  for  years  by 
the  intravenous  use  of  digitalone.  Furthermore,  he  has  found  that  a 
single  injection  of  digitalone  was  often  sufficient  in  cases  of  acute  cardiac 
failure. 


The  Treatment  of  Acute  Pulmonary  (Edema. — Mi  ler  and  Matthews 
{Arch.  Int.  Med.,  1909,  iv,  356)  base  their  article  upon  an  experimental 
research  on  acute  pulmonary  oedema.  They  state  that  a  knowledge  of 
the  causes  producing  an  edema  is  essential  to  its  treatment.  Pulmo- 
nary ce  'ema  is  usually  a  manifestation  of  some  circulatory  disturbance. 
This  circulatory  disturbance  may  be  due  to  high  blood  pressure.  In 
such  a  case  drugs  that  increase  arterial  tension  are  harmful,  and  so  are 
contra-indicated.  The  blood  pressure  should  be  reduced  by  bleeding, 
by  counterirritation  to  the  surface  of  the  body,  or  by  drugs  that  lower 
the  blood  pressure.  On  the  other  hand,  the  type  of  oedema  associated 
with  low  blood  pressure  should  be  treated  by  drugs  raising  the  blood 
pressure.  They  advise  against  the  use  of  atropine  in  pulmonary  oedema 
associated  with  high  arterial  tension.  Atropine  is  frequently  recom- 
mended in  pulmonary  oedema  based  on  its  power  to  lessen  secretions. 
However,  the  oedema  is  not  due  to  an  increase  of  secretion,  but  to  a 
transudation.  They  believe  that  adrenalin  is  probably  never  useful 
and  often  may  be  dangerous.  The  inhalatio  ^  of  oxygen  is  harmless, 
and  often  gives  temporary  relief.  Morphine  is  decidedly  beneficial  in 
any  type  of  pulmonary  oedema  relieving  the  nervous  apprehensions  of 
the  patient. 

Choral  Hydrate  as  a  Local  Application. — Heller  {Munch,  med.  Woch., 
1909,  xlvii,  2418)  has  used  chloral  hydrate  as  a  local  application  in 
various  inflammatory  conditions  of  mucous  membranes.  He  employs 
a  2  per  cent,  solution  of  chloral  hydrate  in  the  form  of  a  spray  in  the 
treatment  of  acute  tonsillitis.    Chloral  hydrate  has  both  antiseptic  and 


PEDIATRICS 


767 


anesthetic  properties,  and  is  especially  useful  to  relieve  pain.  He  found 
it  of  value  in  the  treatment  of  diphtheria,  Vincent's  angina,  syphylitic 
ulcerations,  and  ulcerative  stomatitis.  When  the  secretions  are  foul 
smelling,  chloral  hydrate  also  acts  as  a  deodorant. 


PEDIATRICS. 


UNDER  THE  CHARGE  OF 

LOUIS  STARR,  M.D.,  and  THOMPSON  S.  WESTCOTT,  M.D., 

OF  PHILADELPHIA. 


Unusual  Persistence  in  the  Secretion  of  Colostrum— H.  Merriman 
Steele  (Archiv.  Pediat.,  1910,  xxvii,  32)  reports  the  following  case  of 
persistence  of  the  colostrum  in  a  healthy  young  woman  nursing  her  first 
child.  The  baby  weighed  seven  pounds  and  five  ounces  at  birth  and 
was  normal  in  every  respect.  It  lost  steadily  in  weight,  and  when  it  was 
two  weeks  old  weighed  six  pounds  four  ounces.  It  nursed  regularly, 
seemed  satisfied,  and  had  no  vomiting  or  regurgitation.  The  stools,  at 
first  normal,  now  became  greenish  and  contained  some  mucus  and 
fatty  and  proteid  curds.  There  was  no  fever,  and  the  child  slept  well. 
There  was  scalding  about  the  buttocks,  and  seborrhceic  eczema  developed 
about  the  face  and  chest.  The  mother  had  a  normal  convalescence,  and 
her  milk  was  abundant,  rich,  yellow,  and  thick.  A  sample  taken  for 
analysis,  after  standing  on  ice  for  ten  hours,  showed  a  thick  layer  of  cream 
resembling  butter,  the  whole  specimen  being  a  deep  yellow  with  an  olive 
tint.  Analysis  showed  fat,  3.60  per  cent. ;  proteids,  1 .70  per  cent. ;  specific 
gravity,  1030.  As  this  was  not  far  from  normal  and  the  color  was  pecu- 
liar colostrum  was  suspected.  A  specimen  placed  under  the  microscope 
showed  typical  colostrum.  The  majority  of  the  corpuscles  were  colos- 
trum bodies  and  the  fat  globules  varied  from  minute  to  exceptionally 
large  size.  The  baby  was  taken  from  the  breast  and  given  castor  oil. 
It  was  weaned  on  partially  peptonized  cow's  milk  and  gained  four 
pounds  twelve  ounces  in  nine  weeks.  The  skin  cleared  in  eight  days. 
Colostrum  continued  to  be  secreted  for  three  weeks,  the  last  exami- 
nation showing  precisely  the  same  condition.  In  total,  the  colostrum 
was  secreted  thirty-two  days,  it  being  fairly  assumed  that  the  secretion 
was  colostrum  up  to  the  first  examination. 


Dried  Milk  as  a  Food  for  Infants. — C.  K.  Millard  (Brit.  Med.  Jour., 
1910,  i,  253)  describes  the  preparation  and  use  of  dried  milk  and  the 
results  obtained  from  its  use  as  an  infants'  food.  Dried  milk  is  pre- 
pared by  feeding  fresh  milk  in  a  continuous  stream  on  to  revolving- 
cylinders  heated  by  steam  to  about  250°  F.,  the  moisture  in  the  milk 
being  instantly  dispelled.  A  thin  film  of  dry  milk  forms  on  the  cylinder 
and  is  detached  by  knife-edges.  It  is  subsequently  passed  through  a 
sieve  and  is  obtained  as  a  coarse,  granular,  cream-colored  powder 
practically  sterile,  which,  in  air-tight  packages,  will  keep  almost  in- 


768 


PROGRESS  OF  MEDICAL  SCIENCE 


definitely.  The  relative  proportions  of  the  main  constituents — proteids, 
fats,  milk  sugar,  and  salts — remain  practically  unchanged,  but  changes 
occur  in  the  more  complex  albuminoids  and  enzymes,  similar  to  those 
in  boiled  milk.  The  extremely  short  time  during  which  the  milk  is 
subjected  to  the  heat  by  the  Just-Hatmaker  process  described  above, 
may  cause  less  change  than  occurs  in  boiling.  When  mixed  with  water, 
about  60  per  cent,  of  the  dried  milk  is  soluble,  the  remainder  is  readily 
suspended.  This  dried  milk  has  been  used  at  an  Infants'  Milk  Depot 
for  eighteen  months,  for  about  two  hundred  infants.  One  advantage 
discovered  was  greater  digestibility;  many  infants  with  whom  liquid 
milk  did  not  agree,  thriving  on  the  dried  form,  and  retained  it.  This 
difference  is  accounted  for  by  the  character  of  the  curd  formed  in  the 
stomach  which  does  not  tend  to  form  hard  cheese-like  masses.  All 
infants  not  thriving  on  bottled  milk  were  placed  on  the  dried  milk,  with 
excellent  results.  After  a  period  of  ten  months  or  longer  careful  records 
and  investigations  showed  no  scurvy  or  rickets  resulting  from  its  use 
and  no  bad  after-effects  have  been  discovered.  The  advantages  of  the 
dried  milk  appear  to  be:  Ease  of  digestion,  bacterial  purity — freedom 
from  tubercle  bacilli  and  contamination  by  flies.  Conservatility — no 
"souring"  in  hot  weather.  Convenience — a  definite  quantity  being 
mixed  with  warm  boiled  water.  Cheapness.  The  presumed  destruction 
of  the  antiscorbutic  properties  of  the  milk  is  theoretical,  but  can  be 
compensated  for,  if  thought  necessary,  by  administering  fruit  juice. 
Dried  milk,  being  after  all  "only  milk,"  is  in  an  entirely  different  category 
from  all  patent  foods  prepared  from  cereals,  and  is  superior  to  them. 


Cyclic  or  Recurrent  Vomiting  with  Hypertrophic  Stenosis  of  the  Pylorus. — 

A.  E.  Russell  (Brit.  Jour.  Children's  Dis.,  1910,  vii,  49)  supports 
the  argument  that  muscular  spasm  of  the  pylorus  due  to  hypertrophic 
stenosis  is  sometimes  the  cause  of  cyclic  vomiting  with  its  attendant 
conditions.  He  cites  as  an  example  the  case  of  a  boy,  aged  four  years, 
and  nine  months,  who  from  birth  was  subject  every  few  months  to 
attacks  of  vomiting  with  epigastric  pain.  The  attacks  appeared  sudden- 
denly  and  lasted  twenty-four  hours,  the  vomiting  recurring  during 
the  day.  The  child's  last  illness  began  with  an  attack  lasting  one  week, 
during  which  the  vomitus  turned  from  yellow  to  coffee  color.  There 
was  great  prostration,  emaciation,  and  the  breath  smelled  strongly 
of  acetone.  There  was  constipation  and  the  urine  contained  acetone 
and  diacetic  acid.  Then  a  period  of  remission  occurred  lasting  nineteen 
days,  during  which  the  child  ceased  vomiting,  took  nourishment  and 
improved.  The  urine  became  free  of  acetone  and  diacetic  acid.  There 
was  then  a  return  of  the  vomiting  and  epigastric  pain  and  after  five  days 
the  child  died,  acetone  and  diacetic  acid  again  having  appeared  in  the 
urine.  The  autopsy  showed  a  considerably  dilated  stomach.  The 
lumen  of  the  pylorus  was  very  small  and  its  walls  were  thickened. 
There  was  no  ulcer  or  scar  tissue  present  and  the  remaining  thoracic 
and  abdominal  organs  were  normal.  These  symptoms  are  practically 
identical  with  those  of  cyclic  or  periodic  vomiting  in  children.  The 
current  views  as  to  cyclic  vomiting  are  that  it  is  due  to  a  poisoning 
arising  from  the  intestinal  tract,  with  imperfect  oxidation  of  fats  and  an 
accumulation  of  them  in  the  liver.  Russell  argues  that  acute  starvation 
accompanies  this  condition,  as  evidenced  by  the  emaciation  and  the 


pediatrics 


769 


acetone  bodies  in  the  breath  and  urine  (with  the  fatty  changes  in  the 
liver  often  found  in  these  cases).  He  claims  that  these  latter  conditions 
can  be  explained  by  the  acute  starvation  involved  with  cyclic  vomiting, 
and  that  the  cause  of  the  vomiting  is  elsewhere,  probably  in  the  hyper- 
trophic stenosis  of  the  pylorus.  While  actual  stenosis  of  the  pylorus 
is  not  an  essential  factor  in  the  disease,  he  submits  that  the  attacks 
were  due  to  the  occurrence  of  pyloric  spasm.  On  this  hypothesis,  as 
long  as  pyloric  spasm  lasted  obstruction  would  be  complete.  If  it 
persisted  long  enough,  acute  starvation  would  necessarily  follow  with 
the  resulting  acidosis.  Fatal  issue  followed  on  the  inanition  and  ex- 
haustion. While  possibly  not  a  factor  in  all  cases,  pyloric  spasm  is 
enough  to  account  for  recurrent  attacks  of  vomiting  and  presents  all 
features  described  as  characteristic.  It  is  also  consistent  with  the  fact 
that  the  attack  often  comes  on  suddenly.  Relaxation  of  the  spasm 
would  be  followed  by  this  sudden  cessation  of  the  attack,  which  is 
often  a  noticeable  feature. 


An  Epidemic  of  Acute  Poliomyelitis. — W.  W.  Treves  (Brain,  1909, 
xxxii,  28)  records  the  occurrence  of  an  epidemic  of  8  cases  of  acute 
anterior  poliomyelitis  in  Upminster,  a  town  of  1700  inhabitants.  It  was 
the  first  epidemic  of  its  kind  in  the  town,  and  no  case  of  infantile  paralysis 
had  occurred  there  in  several  years.  The  months  of  the  epidemic 
were  hot  and  dry,  but  the  heat  was  not  excessive.  Six  of  the  patients 
had  constitutional  symptoms  and  a  few  days  afterward  were  paralyzed; 
one  child  had  fever,  but  developed  no  paralysis;  the  eighth  was  paralyzed 
without  any  constitutional  symptoms.  The  legs  were  the  members 
most  commonly  affected.  In  some  of  the  children  the  eyes  attracted 
the  parents'  attention  by  their  peculiar  look,  but  in  no  case  was  any 
definite  evidence  of  polio-encephalitis  obtained.  Seven  of  the  children 
were  over  six  years  of  age,  one  was  three  and  one-half.  In  5  of  the 
cases  the  period  of  incubation  could  not  have  been  more  than  six  days. 
All  attempts  to  trace  the  means  by  which  the  disease  spread  failed. 
Of  32  other  epidemics  recorded  in  literature  and  discussed  by  the 
author,  but  2  occurred  in  England. 


The  Dwarf  Tapeworm,  an  Intestinal  Parasite  in  Children. — Oscar 
M.  Schloss  (Archiv.  Pediat.,  1910,  xxvii)  reports  14  cases  of 
dwarf  tapeworm  or  Hymenolepis  nana,  in  230  children.  The  average 
length  of  the  worm  is  from  14  to  16  mm.  The  distal  half  is  broad, 
while  the  proximal  half  becomes  narrow.  The  segments  are  from 
3  to  6  times  as  broad  as  long  and  the  head  of  the  worm  is  globular  and 
carries  four  suckers  and  a  rostellum  armed  with  twenty  or  thirty  bifid 
hooklets.  Its  habitat  in  man  is  in  the  upper  two-thirds  of  the  ilium. 
The  eggs  are  slightly  oval  and  have  two  membranes  widely  spaced. 
From  the  poles  of  the  inner  membrane  are  projections  from  which 
spring  filaments  which  ramify  in  the  space  between  the  membranes. 
This  is  characteristic.  The  230  children  examined  were  from  the  tene- 
ment-house district,  and,  with  one  exception,  were  all  born  in  New  York 
City.  Six  of  the  14  cases  observed  showed  no  symptoms  referable 
to  the  parasite.  The  remaining  8  cases  showed  gastro-intestinal 
and  nervous  symptoms.  Under  the  former,  epigastric  pain,  nausea, 
vomiting,  and  an  increased  appetite  were  prominent.    Restlessness  at 


770 


PROGRESS  OP  MEDICAL  SCIENCE 


night,  grinding  the  teeth,  itching  of  the  nose,  and  genital  pruritus  under 
the  latter.  Eosinophilia  was  present  in  7  of  the  8  cases  suffering  from 
symptoms  of  the  parasite.  In  cases  with  no  symptoms  eosinophilia 
was  uniformly  absent,  A  secondary  anemia  was  generally  present. 
The  absence  of,  and  variety  in,  symptoms  are  probably  due  to  the  site 
of  mechanical  irritation  in  the  intestine  and  to  toxic  effects.  The  mode 
of  infection  is  through  ingestion  of  the  ova  in  food.  No  intermediate 
host  has  been  found  in  any  human  food.  The  dwarf  tapeworm,  how- 
ever, has  frequently  been  found  in  the  small  intestine  of  rats.  Auto- 
infection  is  possible,  owing  to  the  great  number  of  ova  in  the  feces. 
The  diagnosis  is  made  by  finding  the  characteristic  ova  in  the  feces 
or  by  obtaining  the  parasite  after  treatment.  The  treatment  consists 
of  a  preliminary  period  of  two  or  three  days  on  liquid  diet,  a  preliminary 
purge  and  the  administration  of  oleoresin  of  male  fern  in  mixture, 
emulsion,  or  capsule.  The  dose  for  a  child  two  to  four  years  old  is 
0.5  dram;  four  to  six  years,  40  grains;  and  six  to  twelve  years,  1  dram. 
This  is  given  on  an  empty  stomach.  It  is  divided  into  three  or  five  doses 
and  given  at  half-hour  intervals.  A  brisk  cathartic  is  given  a  half  an 
hour  after  the  last  dose  is  taken.  When  the  treatment  is  not  effective 
the  ova  reappear  in  the  feces  in  fifteen  days. 


OBSTETRICS. 


UNDER  THE  CHARGE  OF 

EDWARD  P.  DAVIS,  A.M.,  M.D., 

PKOFESSOR  OF  OBSTETRICS  IN  THE  JEFFERSON  MEDICAL  COLLEGE,  PHILADELPHIA. 


The  Diagnosis  of  Puerperal  Septic  Infection. — Sachs  (Zent.  f.  Gynak., 
No.  46,  1909)  gives  the  result  of  200  examinations  of  lochial  discharge 
and  blood  in  septic  cases.  This  study  was  made  to  determine  the 
significance  of  hemolytic  streptococci  in  the  blood  as  well  as  in  the  lochial 
discharges.  He  agrees  with  Veit  that  serious  puerperal  septic  infection 
is  caused  by  these  organisms,  which  are  present  in  the  great  majority  of 
cases.  By  using  fluid  blood  agar  media  he  was  able  to  recognize  hemolytic 
streptococci  in  two-thirds  of  the  cases.  It  is  not  sufficient  to  recognize 
a  few  of  these  organisms  to  make  a  diagnosis  of  infection.  Their 
presence  must  be  sought  in  the  blood  and  their  frequency  estimated. 
When  puerperal  ulcers  with  hemolytic  streptococci  are  present  the 
prognosis  is  better  than  if  peritonitis  has  developed.  Recognition  of 
hemolytic  streptococci  in  healthy  puerperal  patients  has  absolutely  no 
significance  with  regard  to  their  importance  in  cases  of  sepsis.  When 
these  germs  are  not  found  in  a  septic  patient,  the  prognosis  is  good. 
As  an  exception  to  this,  are  those  cases  late  in  the  puerperal  period 
in  which  hemolytic  streptococci  have  passed  from  the  uterus  and  have 
caused  suppuration  in  thrombosed  veins,  and  are  no  longer  recognized 
in  the  secretion  of  the  uterus;  also  in  cases  of  sinus  thrombosis  and  other 
intercurrent  affections  in  which  the  streptococcus  is  the  active  agent. 


OBSTETRICS 


771 


In  cases  of  mild  infection  in  greatly  weakened  persons  after  severe 
hemorrhage  or  asphyxia  following  anesthesia,  a  fatal  result  may  follow, 
although  hemolytic  streptococci  are  not  found.  When  peritonitis 
develops  early  in  the  puerperal  period  perforation  of  the  uterus  must 
be  suspected,  and  in  these  cases  hemolytic  streptococci  might  not  be 
obtained  from  the  uterine  cavity.  The  mortality  statistics  of  surgical 
operations  in  streptococcic  peritonitis  give  50  per  cent,  recoveries,  and 
50  per  cent,  deaths.  This  favorable  showing  is  to  be  explained  by 
the  diminished  virulence  of  the  germ,  and  the  fact  that  many  of  these 
cases  are  perforation  of  the  uterus.  The  high  mortality  of  severe  puer- 
peral sepsis  arises  in  great  part  from  the  fact  that  a  differential  diagnosis 
between  the  mild  and  severe  cases  is  not  made  sufficiently  early  to  be  of 
use  in  the  treatment.  Clinical  observation  will  often  determine  the  degree 
of  severity  in  septic  infection,  but  bacteriological  examination  is  a  most 
useful  adjunct. 

Modification  of  Peripheral  Sensation  during  Pregnancy. — Pondolfi 
(Annali  di  Ostetricia  et  Ginecologia,  No.  9,  1909)  contributes  a  paper 
upon  this  subject,  describing  an  apparatus  which  he  has  devised  for 
testing  the  peripheral  sensibility  of  patients  during  pregnancy.  His 
experiments  were  made  upon  the  fingers,  and  in  all  30  cases  were  studied. 
He  concludes  that  peripheral  sensibility  to  pain  during  gestation  is 
very  considerably  decreased. 

Ovariotomy  and  Myomectomy  Early  in  Pregnancy,  with  Full  Term 
Delivery. — Grad  (Jour.  Amer.  Med.  Assoc.,  November  27,  1909) 
reports  the  case  of  a  patient  in  her  first  pregnancy  brought  to  the  hospital 
because  she  had  fainted  on  the  street,  after  complaining  of  sudden 
abdominal  pain,  with  vomiting  and  collapse.  This  pain  gradually 
subsided,  leaving  the  abdomen  tender.  There  was  a  history  of  cramp- 
like pain  in  the  abdomen,  with  moderate  fever,  indigestion,  and  disturb- 
ance of  the  bladder,  for  a  week  or  ten  days  prior  to  this  attack.  The 
patient  had  been  married  nine  years,  but  had  not  previously  been 
pregnant.  On  examination  the  uterus  was  slightly  enlarged,  with 
several  fibroid  nodules.  A  large  movable  tumor  was  also  detected  in 
the  pelvis.  The  diagnosis  of  ovarian  cyst  with  twisted  pedicle  and 
pregnancy  in  a  fibroid  uterus  was  made.  At  operation  the  pedicle  of 
the  cyst  was  ligated  and  the  tumor  removed.  Three  fibroids  were 
enucleated  without  especial  difficulty.  Although  the  patient  had  a 
bloody  discharge  from  the  uterus  after  the  operation,  the  ovum  was 
retained,  and  the  patient  went  to  term  and  was  subsequently  delivered 
by  the  use  of  forceps. 


Ovarian  Cyst  with  Twisted  Pedicle  Complicating  Pregnancy. — Rushmore 
(Surg.,  Gynecol.,  and  Obstet.,  November,  1909)  reports  the  case  of  a  mul- 
tipara, who  on  the  day  before  her  admission  to  the  hospital  had  cramp- 
like pain  low  down  on  the  left  side.  Examination  under  chloroform 
revealed  pregnancy  with  an  ovarian  tumor.  On  opening  the  abdomen 
an  ovarian  cyst  on  the  left  side  with  the  pedicle  twisted  one  and  a 
half  times,  dark  purple,  almost  black  in  color,  was  found.  The  tissue 
was  very  soft  and  friable,  and  the  wall  of  the  uterus  bled  freely.  The 
tumor  was  successfully  removed,  and  the  mother  made  a  good  recovery, 


772 


PROGRESS  OF  MEDICAL  SCIENCE 


a  healthy  child  being  born  at  full  term.  On  examination  the  tumor  was 
a  dermoid  cyst  of  the  ovary  with  strangulated  pedicle  and  a  partial 
strangulation  of  the  Fallopian  tube.  The  article  concludes  with  a 
review  of  the  literature  of  the  subject. 

Artificial  Reproduction  of  the  Amniotic  Liquid  during  Labor. — Schal- 

lehn  (Archiv  f.  Gynak.,  1909,  lxxxix,  Heft  2)  reports  five  cases  of  prema- 
ture escape  of  the  amniotic  liquid,  in  which  Bauer's  elastic  bag  was  intro- 
duced, .distended  with  salt  solution,  and  allowed  to  remain  in  place 
in  the  membranes.  In  several  cases  in  which  the  heart  sounds  had  be- 
come weakened  through  birth  pressure  they  improved  after  the  bag 
was  introduced.  If  the  patient  suffered  much  pain  from  pressure, 
morphine  was  given  hypodermically,  and  the  patient  was  delivered  so 
soon  as  the  cervix  was  dilated  by  version  or  forceps.  The  presence 
of  the  bag  seemed  to  excite  uterine  contractions  and  lessen  the  risk  of 
fatal  birth  pressure  for  the  child.  It  was  used  in  these  cases,  not 
primarily  to  dilate  the  cervix,  but  to  protect  the  child  from  pressure; 
secondarily  to  soften  the  cervix  and  expedite  labor. 

The  Results  of  Pregnancy  Occurring  After  Operations  for  the  Correction 
of  Retroflexion. — Birnbaum  {Archiv  f.  Gynak.,  1909,  lxxxix,  Heft  2) 
reports  the  results  in  20  cases  operated  upon  for  retroflexion  by  ventro- 
fixation. In  4  of  these  pregnancy  occurred,  terminating  in  labor  with- 
out complications.  In  these  cases  there  were  evidences  of  peritoneal 
adhesions  and  alterations  of  the  tubes  and  ovaries.  These  were  de- 
tected at  the  operation.  The  cause  of  the  sterility  which  had  existed 
before  operation  seemed  to  be  the  kinking  in  the  Fallopian  tubes,  which 
was  caused  by  the  retroflexed  condition  of  the  uterus.  In  3  cases  no 
cause  could  be  found  at  operation  for  the  peritoneal  adhesions;  in  1 
case  a  previous  parametritis  had  undoubtedly  existed.  In  the  16  other 
cases  in  which  operation  was  done  for  retroflexion,  pregnancy  had  not 
occurred  at  the  time  of  writing.  It  is  questionable  whether  lesions 
indirectly  produced  by  the  retroflexion  were  not  responsible  for  the 
sterility  in  these  cases. 


GYNECOLOGY. 


UNDER  THE  CHARGE  OF 

J.  WESLEY  BOVEE,  M.D., 

PROFESSOR  OF  GYNECOLOGY  IN  THE  GEORGE  WASHINGTON  UNIVERSITY,  WASHINGTON,  D.  C. 


An  Ovarian  Abscess  Containing  a  Lumbricoid  Worm. — Fry  (Jour. 
Amer.  Med.  Assoc.,  1909,  liii,  1028)  reports  a  case  of  ovarian  abscess 
that  contained  a  lumbricoid  worm.  The  patient  was  twenty-three 
years  of  age.  The  right  appendage  was  inflamed  and  adherent. 
The  left  ovary  and  tube  were  adherent  to  the  uterine  cornu.  The 
ovary  was  enlarged  to  the  size  of  a  hen's  egg,  the  surface  smooth  and 


GYNECOLOGY 


773 


non-adherent  to  intestine.  It  ruptured  during  removal  and  30  c.e. 
of  pus  escaped  into  the  abdominal  cavity.  Projecting  from  the  abscess 
through  the  rupture  was  a  lumbricoid  worm  6  or  7  cm.  in  length.  It 
was  dead  and  flattened.  The  worm  was  identified  by  Dr.  B.  H.  Ransom 
of  the  United  States  Department  of  Agriculture.  The  pus  contained 
Bacillus  coli  communis  in  pure  culture.  Fry  concluded  the  worm  had 
gained  access  to  the  ovary  by  the  vaginal  route  and  entered  the  ovary 
through  a  ruptured  Graafian  follicle. 

The  Choice  of  Operations  for  Retrodisplacements  of  the  Uterus. — 

Benjamin  (Jour.  Amer.  Med.  Assoc.,  1909,  liii,  1072)  states:  Retro- 
displacements  of  the  uterus  often  cause  much  discomfort.  The  har- 
monious action  of  all  the  supports  is  essential  to  the  uterus  for  its  normal 
position.  The  operation  which  interferes  with  the  laws  governing 
the  normally  placed  uterus  is  not  to  be  advocated.  The  operation 
which  produces  unnecessary  intra-abdominal  traumatism  should  not  be 
chosen  in  the  ordinary  case.  Operations  which  could  possibly  interfere 
with  the  enlargement  of  the  uterus  during  pregnancy  should  be  used  in 
selected  cases  only.  Operations  which  leave  an  additional  suture 
line  within  the  abdomen  may  cause  subsequent  trouble.  Operations 
which  do  not  give  as  strong  a  support  as  possible  consistent  with  the 
normal  functions  of  the  uterus  may  result  in  failure  in  some  cases. 
The  operation  which  utilizes  the  normal  ligaments  with  little  or  no 
traumatism  is  less  troublesome  and  more  scientific.  Benjamin  then 
describes  his  modification  of  Gilliam's  operation  for  shortening  the 
round  ligaments  and  gives  the  advantages  of  it. 

The  Endometrium  and  Some  of  its  Variations. — Gardner  and  Novak 
(Jour.  Amer.  Med.  Assoc.,  1909,  liii,  1155)  deprecate  the  employment 
of  many  terms  in  quite  common  use,  that  are  now  known  to  have  been 
coined  from  mistakes  in  pathology.  They  believe  Hitschmann  and 
Adler  have  taken  an  extreme  view  in  practically  asserting  that  glandular 
changes  do  not  occur  except  in  connection  with  the  menstrual  process. 
Both  animal  experimentation  and  clinical  observation  indicate  that  the 
actual  underlying  cause  of  menstruation  is  the  secretory  activity  of  the 
ovary,  which  produces  an  internal  secretion  or  hormone  essential  for 
its  occurrence.  The  principal  effort  of  this  substance  seems  to  be  of 
a  vasomotor  nature,  and  is  exerted  especially  on  the  pelvic  bloodvessels. 
It  is  only  natural  to  suppose  that  the  endometrium  plays  a  purely  passive 
role  in  this  phenomenon,  and  that  the  histological  changes  observed 
in  connection  with  menstruation  represent  merely  the  reaction  of  the 
endometrium  to  the  process — a  reaction  which  may,  however,  be  elicited 
by  influences  other  than  that  of  normal  menstruation. 


Factors  which  Contribute  to  a  Reduction  in  Mortality  in  Abdominal 
Surgery— F.  F.  Simpson  (Jour.  Amer.  Med.  Assoc.,  1909,  liii,  1173) 
discusses  in  detail  the  factors  contributing  to  a  minimum  mortality 
rate  in  abdominal  surgery.  While  it  is  a  paper  not  amenable  to 
being  satisfactorily  abstracted,  his  conclusions  may  be  considered 
as  follows:  An  accurate  knowledge  of  the  nature,  extent,  and  kind 
of  disease,  and  exact  determination  of  the  patient's  margin  of  reserve 
strength;  a  judicious  adaptation  of  the  time  and  type  of  operation  to 


774 


PROGRESS  OF  MEDICAL  SCIENCE 


individual  needs;  a  group  of  competent  operative  co-workers;  a  minimum 
amount  of  anesthetic;  a  rigid  aseptic  technique;  and  speed  with  pre- 
cision, are  factors  which  will  yield  a  low  mortality  and  highly  satisfactory 
operative  results. 

The  Age  of  Menstruation  in  Egyptian  Girls.— Mes.  B.  Sheldon  Elgood, 
Assistant  Medical  Officer,  Ministry  of  Public  Instruction,  Cairo  {Jour. 
Obst.  and  Gyn.  of  Brit.  Emp.,  1909,  xvi,  242)  has  studied  the  subject 
of  the  date  of  first  menstruation  in  Egyptian  girls,  her  field  of  inquiry 
being  several  large  schools  for  native  Egyptian  girls.  In  83  menstru- 
ating girls,  the  birth  certificates  of  whom  were  available,  she  found  the 
first  appearance  of  menstruation  in  12  was  at  twelve  years;  in  44,  at 
thirteen  years;  in  21,  at  fourteen  years;  and  in  4,  at  fifteen  years.  This 
study  tends  to  prove  that  at  thirteen  and  fourteen  years  80  per  cent, 
of  native  Egyptian  girls  begin  to  menstruate. 

The  Anatomy  of  Tubal  Convolutions  and  the  Mechanism  of  Tubal  Occlu- 
sion.— James  Young  (Jour.  Obst.  and  Gyn.  Brit.  Emp.,  1909,  xvi,  307) 
states  that  his  analysis  of  the  various  theories  advanced  to  explain 
the  disappearance  of  the  tubal  fimbriae  reveals  the  fact  that  they  fall 
under  one  or  other  of  two  headings:  (1)  The  first  class  includes  the 
theories,  which  explain  the  process  as  being  due  to  an  increase  in  the 
total  length  of  the  tube  wall,  which,  by  expanding  in  an  outward  direc- 
tion, becomes  projected  beyond  the  tubal  fimbria?.  According  to  the 
theory  of  Alban  Doran,  which  receives  the  support  of  Kleinhans,  the 
increase  in  length  is  dependent  on  the  swelling  and  increase  in  substance 
of  the  tube  wall  associated  with  salpingitis,  etc.  According  to  Emil 
Ries  the  gliding  outward  of  the  "peritoneal  ring"  over  the  fimbria?  is 
rendered  possible  by  the  fact  that  the  walls  become  loose  and  redundant 
subsequent  to  the  collapse  of  a  distended  tube.  (2)  In  the  second 
category  are  included  the  theory  of  Opitz,  which  explains  the  process 
as  due  to  retraction  of  the  muscular  and  mucous  coats  of  the  tube 
within  the  serous  coat,  and  the  theory  described  in  this  paper,  in  which 
the  gliding  process  involves  only  the  mucosa  and  inner  coat  of  muscle. 
In  the  so-called  "perimetritic  closure"  of  Alban  Doran  the  sealing  of 
the  opening  is  explained  by  a  matting  together  of  the  fimbria?  by  inflam- 
matory adhesions  without  a  preliminary  recession. 

Removal  of  an  Unusually  Large  Ovarian  Tumor . — Knight  (Amer.  Jour. 
Obst.,  1909,  lxi,  441)  reports  the  successful  removal  by  abdominal 
section  of  an  ovarian  cyst  weighing  one  hundred  and  eleven  pounds., 
It  had  been  observed  for  ten  years  by  the  patient  and  was  removed 
without  preliminary  aspiration. 

Enucleation  of  Uterine  Myorrsas;  Why  and  When  Performed. — Mont- 
gomery (Jour.  Amer.  Med.  Assoc.,  1909,  liii,  1245)  suggests  the  fol- 
lowing conditions  as  indicating  hysteromyomecxomy :  (1)  When  the 
growths  are  few  in  number  and  the  structure  of  the  uterus  is  but  little 
involved.  Of  course,  the  fibroids  may  be  numerous  but  situated  so 
near  the  surface  as  to  permit  their  removal  with  but  little  injury  to  the 
general  structure,  but  the  large  number  indicates  a  tendency  to  fibroid 
degeneration  which  presages  early  redevelopment.    When  a  number 


OPHTHALMOLOGY 


775 


of  growths  of  considerable  size  are  present,  the  structure  of  the  uterus 
is  so  spread  out  and  will  be  so  injured  as  to  render  an  attempt  to  save 
the  organ  attended  with  danger  during  the  subsequent  convalescence 
and  an  element  of  danger  in  the  event  of  pregnancy  and  labor.  (2) 
When  the  growths  are  readily  accessible  through  the  vagina  or  cervical 
canal.  A  growth  within  the  uterus,  either  a  sessile,  submucous,  or  an 
interstitial,  is  readily  attacked.  Not  infrequently,  the  canal  may  be 
partially  dilated  and  the  dilatation  can  be  completed  by  the  introduction 
of  tents,  or  the  cervix  may  be  split  bilaterally  until  the  tumor  is  exposed 
or  rendered  accessible.  The  enucleation  completed,  the  cavity  may  be 
packed  with  gauze  and  the  split  cervix  closed  much  as  is  done  in  an 
ordinary  trachelorrhaphy.  The  vaginal  operations  are  attended  with 
less  constitutional  disturbances  than  in  the  removal  by  an  abdominal 
incision.  (3)  When  the  woman,  whether  unmarried  or  married,  is 
under  forty  years  of  age,  and  particularly  when  she  is  childless  or  has 
but  one  or  two  children.  The  removal  of  the  growths  at  an  earlier 
period  cannot  be  considered  as  rendering  certain  the  escape  of  the 
patient  from  recurrence,  for  one  of  his  patients  who  had  two  fibroids 
enucleated  when  she  was  thirty-three  years  old,  five  years  later  had 
twenty  removed.  The  age  of  forty,  however,  is  one  at  which  the  indi- 
vidual suffering  from  such  growths  begins  to  undergo  retrogressive 
degenerations,  and  when  the  patient  has  not  previously  been  fertile 
pregnancy  is  much  less  likely  to  occur.  (4)  When  the  tubes  and  ovaries 
are  free  from  complicating  conditions.  The  existence  of  tubal  or 
ovarian  disease  of  sufficient  gravity  (as  hydrosalpinx,  or  pyosalpinx, 
or  ovarian  hematoma),  to  render  the  probability  of  conception  remote 
or  to  necessitate  the  removal  of  tubes  and  ovaries  to  insure  restoration 
of  health,  should  also  be  an  indication  for  the  removal  of  the  fibro- 
myomatous  uterus.  While  it  is  true  that  in  the  majority  of  cases  the 
tumors  decrease  and  become  quiescent  after  the  menopause,  yet  they 
sufficiently  often  undergo  necrosis  and  other  degenerative  changes  to 
justify  the  removal  of  the  uterus. 


OPHTHALMOLOGY. 

EDWARD  JACKSON,  A.M.,  M.D., 

OF  DENVER,  COLORADO, 
AND 

T.  B.  SCHNEIDEMAN,  A.M.,  M.D., 

PROFESSOR  OF  DISEASES  OF  THE  EYE  IN  THE  PHILADELPHIA  POLYCLINIC. 


Treatment  of  Detachment  of  the  Eetina. — Deutschmann  (Ophthalmo- 
scope, November,  1909,  p.  737),  in  demonstrating  his  methods  of  oper- 
ating for  this  condition,  bisection  and  injection  of  the  sterile  vitreous 
humor,  formulates  the  following  rules:  Bisection:  never  operate 
upon  a  recent  detachment  so  long  as  the  detached  part  is  situated  in  the 
upper  part  of  the  fundus;  the  bisection  is  to  be  made  with  a  double-edged 
linear  knife  downward  in  the  anterior  boundary  of  the  cul-de-sac. 


776 


PROGRESS  OF  MEDICAL  SCIENCE 


Bisect  horizontally,  guide  the  knife  tangentially  to  the  eyeball  from 
downward  and  outward  to  downward  and  inward.  Make  the  bisection 
as  quickly  as  possible  in  a  straight  direction  through  the  eyeball  avoiding 
the  junction  at  the  spot  of  the  counter  puncture,  and  draw  back  the  knife 
in  the  same  way  it  was  introduced.  Turn  the  blade  a  little  at  the  spot 
of  the  puncture,  so  that  the  retinal  and  eventually  the  preretinal  fluid 
can  escape.  The  operation  can  be  repeated  twenty  times  or  oftener 
unless  interference  has  been  followed  by  any  unfavorable  result.  Band- 
ages should  be  applied  to  both  eyes  for  the  first  twenty-four  hours  and 
then  only  upon  the  operated  one  for  four  or  five  days.  Atropine  should 
be  employed  during  the  entire  treatment  and  the  patient  kept  in  bed  for 
a  week  after  each  operation.  The  injection  method  is  reserved  for 
cases  otherwise  hopeless. 

Myopia  and  Light  Sense. — Landolt  (Klin.  Monatsbl.  f.  Augenhk., 
'October,  1909,  p.  369)  concludes  that  the  light  sense  is  not  influenced 
in  myopia  even  of  high  degree  unless  decided  chorioretinal  changes  are 
present,  and  even  the  latter  do  not  always  diminish  that  function; 
neither  does  astigmatism  have  any  effect,  and  light  sense  and  visual 
acuity  are  independent  of  each  other.  Age,  however,  appears  to  dimin- 
ish the  faculty  in  myopes  as  well  as  in  emmetropes  and  hyperopes. 

Report  upon  103  Cases  of  Magnet  Extractions. — Hausmann  (Klin. 
Monatsbl.  f.  Augenh.,  1910,  xlvii,  86)  reports  that  of  103  magnet 
extractions  from  the  ophthalmic  clinic  of  the  University  of  Halle,  the 
vision  ranged  from  f  to  T\  in  37  cases;  from  ^  to  -g1^  in  11  cases;  and 
less  than  -fa  in  the  same  number;  in  15  cases  the  form  of  the  eyeball 
was  maintained,  though  the  vision  was  lost;  in  7  there  was  phthisis 
bulbi,  and  in  22  enucleation  or  evisceration  had  to  be  performed. 


Etiology  of  Subacute  and  Tardy  Infection  Following  Operations. — 

(Ophthalmic  Section  of  XVIth  International  Congress  of  Medicine, 
Budapest,  La  Clin.  OphtaL,  November  10,  1909,  p.  567).  Following 
a  lengthy  discussion  upon  the  infectious  complications  which  sometimes 
follow  iridectomy,  extraction  of  cataract,  discission,  sclerotomy,  and 
other  operations  upon  the  cornea,  iris,  uveal  tract,  or  vitreous  body, 
Mo  rax  comes  to  the  following  conclusions:  The  tardy  appearance  of 
an  iridociliary  infection  of  subacute  development  can  be  provoked  by 
a  late  development  of  pyogenic  microbes,  which  have  been  introduced 
at  the  time  of  the  operation.  Although  bacteriological  examinations 
are  still  liable  to  be  misinterpreted  and  while  the  explanation  of  the 
majority  of  such  cases  of  iridocyclitis  is  purely  hypothetical,  the  reporter 
is  inclined  to  believe  that  they  are  in  general  due  to  the  development 
of  little  known  saprophytes  and  still  undescribed  spores  which  have 
their  seat  upon  the  surface  of  the  conjunctiva  of  certain  individuals. 
These  germs  offer  to  the  usual  methods  of  disinfection  of  the  conjunc- 
tival cul-de-sac  greater  resistance  than  the  ordinary  pyogenic  microbes. 
At  the  same  session  Angelucci  considered  postoperative  inflammations 
caused  by  auto-infection.  Senile  and  arthritic  albuminuria  occasion 
no  interference  with  the  cicatrization  of  wounds;  grave  forms  of  Bright' s 
disease,  however,  frequently  give  rise  to  iritis.  Neither  does  diabetes, 
save  in  its  graver  forms,  interfere  with  the  healing  process,  Gout 


OPHTHALMOLOGY 


777 


introduces  no  complications  except  when  there  is  also  disturbance  of 
the  intestinal  tract.  Postoperative  iritis  frequently  appears  in  con- 
nection with  dental  suppuration,  constipation  or  intestinal  infection, 
and  occasionally  also  in  vesical  catarrhs.  Influenza  may  provoke 
endogenous  suppuration  in  an  eye  recently  operated  upon,  and  so 
may  furunculosis  and  abscesses,  no  matter  where  situated. 


Nervous  Asthenopia  from  Electric  Light;  Use  of  Yellow  Glasses. — 

De  Waele  (Archiv.  d'Ophtal.,  September,  1909,  p.  566)  publishes 
six  instances  in  young  persons  in  whom  asthenopia  was  produced  by 
working  under  arc  lights.  While  the  electric  light  may  be  no  richer 
in  ultra-violet  rays  than  solar  light,  the  former  is  more  dangerous 
because  the  eye  is  more  directly  exposed.  Electric  lights  should  be 
provided  with  glass  globes  (yellow  is  the  best),  or  at  least  so  placed  or 
screened  that  the  eyes  shall  be  protected  from  the  direct  rays.  When 
this  can  not  be  done  yellow  glasses  should  be  worn. 

Trachoma  in  the  Abruzzi,  Italy. — Guiseppe's  (Xlth  International 
Congress  of  Ophthalmology,  Rec.  d'Ophtal.,  August,  1909,  p.  255) 
statistics  show  what  ravages  trachoma  causes  in  that  country;  in  a 
population  of  147,000,  more  than  2000  cases  of  trachoma  are  known. 
The  disease  is  especially  common  in  the  valleys,  the  mountains  being 
almost  exempt.  In  many  communities  the  malady  has  been  imported 
by  Italian  emigrants  returning  from  Brazil. 


Subcutaneous  Injections  of  Alcohol  in  Blepharospasm  and  Spastic  Entro- 
pion.— Fumagalli  (Annali  di  Oftal.,  1909,  xxviii,  fasc.  3,  p.  162),  at  the 
Clinic  of  Turin,  makes  the  injections  superficially  in  the  neighborhood 
of  the  stylomastoid  foramen  under  the  skin,  in  the  region  of  the  supra- 
orbital nerve  and  of  its  palpebral  filaments  and  in  the  distribution  of 
the  orbital  filaments  of  the  facial  so  as  to  affect  the  orbicularis.  Thirty 
parts  of  absolute  alcohol  and  60  of  sterilized  water  is  the  injection 
employed  without  an  anesthetic.  A  syringeful  (Pravaz)  is  used  for 
the  supra-orbital  region,  and  in  inveterate  cases  of  essential  blepharo- 
spasm a  similar  quantity  is  employed  for  the  infra-orbital  region.  A 
single  injection  under  the  skin  of  the  lid,  in  the  centre  and  parallel  to 
the  free  border,  suffices  in  spasmodic  entropion  (children  and  the  aged). 
Several  injections  may  be  made  daily  or  at  longer  intervals  until  cure 
or  considerable  amelioration  is  obtained. 


Helmholt's  Theory  of  Accommodation. — Rocw(Rec.  d'Ophtal, October, 
1909,  p.  325)  observed  a  case  of  complete  bilateral  ectopia  of  the  lens. 
The  aphakic  portion  of  the  pupil  was  hyperopic  10  D.;  the  portion 
opposite  the  lens  was  myopic  13  D.  This  case  and  others  like  it  furnish  a 
conclusive  argument  in  favor  of  Helmholt's  view  that  during  accommo- 
dation the  zonula  is  relaxed,  against  the  opinion  of  Tscherning  that  the 
act  of  accommodation  is  brought  about  by  tension  of  that  membrane. 
The  fact  that  increase  of  the  refraction  is  not  always  observed  in  luxa- 
tion of  the  lens  may  be  due  to  the  circumstance  that  the  fibers  of  the 
zonula  are  not  completely  torn  through — there  is  subluxation,  a  com- 
paratively small  number  of  fibers  being  sufficient  to  maintain  the  shape 
of  the  lens. 


778 


PROGRESS  OF  MEDICAL  SCIENCE 


PATHOLOGY  AND  BACTERIOLOGY. 


UNDER  THE  CHARGE  OF 

WARFIELD  T.  LONGCOPE,  M.D., 

DIRECTOR  OF  THE  AYER  CLINICAL  LABORATORY,  PENNSYLVANIA  HOSPITAL, 
ASSISTED  BY 

G.  CANBY  ROBINSON,  M.D., 

CLINICAL  PATHOLOGIST  TO  THE  PRESBYTERIAN  HOSPITAL,  PHILADELPHIA. 


The  Nature  of  Antitrypsin  in  the  Bleed  Serum  and  its  Mode  of  Action  — 

Pick  and  Pribram  have  shown  that  when  the  blood  serum  is  treated 
with  ether  it  is  robbed  entirely  of  its  antitryptic  qualities.  This  natur- 
ally suggests  that  the  antifermentive  property  of  the  serum  is  in  some 
way  dependent  upon  the  presence  of  lipoid  substances.  O.  Schwarz 
(Wien.  klin.  Woch.,  1909,  xxii,  1151)  has  reported  and  confirmed  these 
experiments,  and  in  investigating  the  subject  still  further  brings  out 
many  points  of  interest.  He  has  found  that  5  per  cent,  emulsion  of 
lipoid  will  inhibit,  though  not  as  powerfully  as  the  same  quantity  of 
blood  serum,  the  proteolytic  action  of  trypsin.  Blood  serum  which  has 
been  inactivated  by  extraction  with  ether  may  be  re-activated  again  by 
the  addition  of  amounts  of  lipoid  emulsion,  not  in  thenselves  markedly 
antitryptic.  The  re-activation  does  not  take  place,  however,  unless 
the  lipoid  and  serum  are  allowed  to  remain  in  contact  for  one  hour 
at  65°  C.  It  seems,  therefore  probable  that  the  lipoids  must  form  a 
combination  with  albuminous  substances  of  the  serum  in  order  to  assume 
an  antitryptic  power.  It  could  further  be  shown  that  when  this  al- 
bumin-lipoid  complex  is  brought  in  contact  with  a  solution  of  trypsin 
a  portion  of  the  trypsin  is  actually  used  upland  is  probably  bound  to 
the  inhibiting  substance.  As  far  as  could  be  learned  the  antitryptic 
and  antipeptic  properties  of  the  serum  are  not  identical,  for  when  the 
serum  was  inactivated  by  ether  extraction  for  trypsin  it  was  .still  active 
against  pepsin.  Finally,  in  a  few  isolated  experiments,  it  could  be 
shown  that  the  antitryptic  property  of  the  serum  increased  in  proportion 
to  the  amount  of  lipoids  present.  Many  observations  have  been  made 
upon  the  antitryptic  and  antileukoproteolytic  power  of  the  serum  in 
various  diseases,  and  this  property  has  been  found  to  vary  widely,  but 
a  number  of  observations  seem  to  show  that  an  increase  in  the  anti- 
tryptic and  antileukoproteolytic  property  accompanies  an  increase 
in  the  number  of  white  cells.  This  Schwarz  believes  is  due  to  the 
destruction  of  cells  with  subsequent  liberation  of  lipoids  and  not,  as 
has  been  suggested,  to  the  formation  of  a  true  antiferment  in  the  sense 
of  an  antibody,  through  the  liberation  of  ferment  substances  in  the  blood. 

The  Venous  Pulse  under  Normal  and  Pathological  Conditions.— Rihl 

(Zeit.  f.  Exp.  Path,  and  Ther.,  1909,  vi,  619)  discusses  extensively 
from  an  experimental  point  of  view  the  mechanism  of  the  venous  pulse, 
and  his  work  must  be  the  final  word  on  a  number  of  points.  In  his 
experiments  133  dogs  were  used,  and  observations  were  made  with  the 


PATHOLOGY  AND  BACTERIOLOGY 


779 


thorax  both  opened  and  closed.  He  found  that  the  placing  of  a  funnel 
over  the  pulsating  parts  gave  more  delicate  results  than  when  a  mano- 
meter was  used.  The  three  principal  venous  waves,  the  a,  the  c,  and 
the  v  waves  are  discussed  separately.  Rihl  concludes  that  the  a  wave 
is  caused  entirely  by  the  auricular  systole.  An  actual  column  of  blood 
is  sent  up  into  the  vein  by  the  auricle  and  the  pressure  of  this  column 
carries  the  wave  above  the  intact  vein  valves.  It  is  not  a  passive  or 
congestive  wave.  The  a  wave  is  increased  by  increase  of  auricular 
systole,  auricle  and  ventricle  contracting  simultaneously,  and  by  venous 
engorgement.  The  latter  cause  may  increase  the  wave  even  when  the 
auricular  systole  decreases.  The  a  wave  is  diminished  by  a  decrease 
of  auricular  systole,  and  from  this  cause  it  may  disappear.  The  ven- 
tricular activity  causes  two  venous  waves,  the  c  wave  and  the  v  wave. 
These  occur  when  the  ventricle  contracts  without  the  auricle.  The 
c  wave  is  not  dependent  on  the  motion  of  the  aorta  or  carotid  artery. 
The  c  wave  and  the  carotid  pulse  are  synchronous  when  funnels  are 
used  on  both  sides,  and  the  c  wave,  which  follows  a  little  after  the 
systolic  contraction,  is  not  effected  by  the  presence  or  absence  of  the 
auricular  systole.  When  the  venous  wave  is  taken  from  a  deeply 
inserted  cannula  in  the  heart  the  c  wave  is  synchronous  with  the 
ventricular  systole.  The  relation  between  the  a  wave  and  c  wave 
depends,  in  part,  on  the  time  between  the  a  and  v  systole,  but  is  also 
dependent  on  the  size  of  the  a  wave.  Too  much  dependence  should 
not,  therefore,  be  put  in  this  relation  in  determining  the  state  of  the 
conduction  of  the  heart  beat.  The  v  wave  commences  during  ventric- 
ular systole,  and  this  fact  shows  that  it  is  not  dependent  on  ventricu- 
lar diastole  for  its  formation.  This  wave  is  best  considered  as 
formed  by  two  forces,  the  engorgement  of  the  vein  during  ventricular 
systole,  and  the  movement  of  the  base  of  the  heart  upward  at  the 
beginning  of  diastole.  When  a  division  occurs  in  the  v  wave  corre- 
sponding to  the  point  where  the  two  forces  meet,  it  is  synchronous 
with  the  dicrotic  notch,  as  seen  in  the  carotid  artery  tracing.  This 
division  represents,  therefore,  the  opening  of  the  atrioventricular  valves. 
This  v  wave  is  increased  and  decreased  with  the  increase  and  decrease 
of  venous  engorgement.  Slight  tricuspid  lesions  cause  no  changes  in 
the  v  wave,  but  grave  lesions  increase  it  and  make  it  come  earlier  in 
systole.  Only  with  the  highest  grade  lesions  does  the  ventricular  type 
of  venous  pulse  occur. 

The  Cause  of  Arteriosclerosis. — Harvey  (Virch.  Archiv,  1909,  cxcvi, 
303),  attempting  to  discover  what  part  increased  blood  pressure  might 
play  in  the  production  of  arteriosclerosis,  has  compressed  the  abdominal 
aorta  of  young  rabbits  for  three  minute  periods  over  a  prolonged  time. 
By  actual  manometric  tracing  it  was  found  that  digital  compression  of 
the  aorta  in  rabbits  raises  the  blood  pressure  at  times  42  mm.  It  was 
found  that  by  this  method  extensive  sclerosis  could  be  produced  in  the 
aorta  above  the  point  of  compression.  The  sclerosis  was  of  the  type 
described  by  Monkeberg  in  man,  and  consisted  in  degeneration  of  the 
muscular  coat  with  deposits  of  lime  salts.  Harvey  believes  that  the 
sclerosis  produced  in  rabbits  by  injection  of  adrenalin,  nicotine,  etc., 
is  caused  not  by  a  toxic  action  of  the  drugs,  but  by  their  power  to  increase 
blood  pressure. 


•r 
I 


780  PROGRESS  OP  MEDICAL  SCIENCE 

Changes  in  the  Chromaffin  System  in  Cases  of  Unexplained  Postoperative 
Death. — Joseph  Hornowski  (Virchow's  Archiv,  1909,  cxcviii,  98) 
points  out  that  sudden  death  after  operation,  with  symptoms  of  shock, 
has  been  explained  by  hypotheses  only — e.  g.,  chloroform,  heart  failure, 
etc.  He  argues  however,  that  this  is  not  correct  and  that  such  definite 
clinical  symptoms  as  these  cases  present  must  have  an  equally  definite 
cause.  This  cause  he  attempts  to  show  lies  in  the  so-called  "phao- 
chrome"  or  chromaffin  cells  of  the  adrenal  glands  and  sympathetic 
ganglia,  and  brings  forward  as  an  analogy  the  extreme  asthenia  of 
Addison's  disease  in  which  these  cells  show  marked  change.  This  change 
is  a  loss  of  brown  color  when  stained  by  chrome  salts  In  four  cases  of 
death  shortly  after  operation  he  found  the  phaochrome  cells  of  the  ad- 
renals and  sympathetic  ganglia  either  colorless  or  only  very  faintly  yellow. 
From  these  and  other  unreported  observations  Hornowski  concludes 
that  the  pale  appearance  of  these  cells  is  the  sign  of  a  lack  of  activity 
on  their  part,  or  a  lack  of  the  "  pressure-maintaining  substance"  which 
they  produce  and  is,  therefore,  sufficient  to  explain  death  in  the  absence 
of  other  causes.  With  this  hypothesis  as  a  starting  point  the  author 
reasons  that  the  blood-pressure-lowering  effect  of  chloroform  is  offset 
by  the  secretions  of  the  chromaffin  cells.  This  extra  call  upon  the  cells 
tends  to  exhaust  them,  but  in  addition  the  drug  exerts  a  toxic  action 
upon  them,  so  that  a  point  is  reached  where  the  cells  are  no  longer  able 
to  meet  the  vital  demand  and  death  ensues.  As  suggestive  corrobora- 
tive clinical  observations  the  author  mentions  the  occurrence  of  death 
in  those  cases  in  which  the  patient  passes  through  a  long  period  of 
excitation  in  the  first  stages  of  anesthesia  and  consequently  uses  a  greater 
amount  of  the  "pressure-maintaining  substance."  Furthermore  he 
cites  those  patients  that  feel  unduly  well  and  bright  immediately  after 
operation  and  then  go  on  to  sudden  death.  This  stimulated  condition 
he  believes  is  a  manifestation  of  excessive  production  of  the  substance,  and 
the  rapid  subsequent  collapse  evidence  of  exhaustion  of  the  chromaffin 
cells.  Hornowski  then  undertook  animal  experiments.  He  anesthetized 
rabbits  for  various  lengths  of  time  and  also  injured  the  sympathetic 
ganglia.  He  found  that  short  deep  chloroforming  produced  no  change 
in  the  phaochrome  cells.  Repeated,  long  chloroforming,  however, 
caused  the  cells  to  fail  to  take  the  chrome  stain.  Trauma,  on  the  other 
hand,  to  the  peritoneum,  adrenals,  and  sympathetics,  produced  rapid 
loss  of  color  in  the  cells  of  the  chromaffin  system.  The  author  concludes 
that  the  brown  color  (chrome  reaction)  is  an  indication  of  the  power 
of  the  cells  to  produce  the  "  pressure-maintaining  substance,"  and  that 
if  the  organism  can  meet  the  increased  demand  for  this  substance  caused 
by  chloroform  and  trauma — in  the  face  of  the  toxic  effect  of  the  chloro- 
form— death  does  not  occur. 


Notice  to  Contributors. — All  communications  intended  for  insertion  in 
the  Original  Department  of  this  Journal  are  received  only  with  the  distinct 
understanding  that  they  are  contributed  exclusively  to  this  Journal. 

Contributions  from  abroad  written  in  a  foreign  language,  if  on  examination 
they  are  found  desirable  for  this  Journal,  will  be  translated  at  its  expense. 

A  limited  number  of  reprints  in  pamphlet  form,  if  desired,  will  be  furnished 
to  authors,  provided  the  request  for  them  be  written  on  the  manuscript. 

All  communications  should  be  addressed  to — 

Dr.  A.  0.  J.  Kelly,  1911  Pine  Street,  Philadelphia,  U.  S.  A. 


A  Vaginal  Tampon  of 


"\  V  7E  find  that  the  use  of  Antiphlogistine  in  vaginal  tampons  is  a  new 
thought  to  many  a  physician,  but  when  he  once  learns  of  it, 
he  wonders  that  he  has  not  used  it  in  that  way  before.  In  fact,  Anti- 
phlogistine makes  the  ideal  tampon,  for  while  its  hygroscopic  properties 
deplete  the  congested  parts,  its  plastic  nature  affords  the  required  support. 

TECHNIQUE. — Place  the  requisite  quantity  of  Antiphlogistine  in  the  centre  of  a  square  of  gauze, 
gather  the  edges  up  around  the  Antiphlogistine,  bag-fashion,  tie  a  string  around  the  neck  of  the  bag  and 
insert  through  a  speculum. 

Wherever  inflammation  or  congestion  is  a  factor,  Antiphlogistine  is  indicated  and  should  always  be 
applied  warm  and  thick  and  covered  with  absorbent  cotton. 


THE  DENVER  CHEMICAL  MFG.  CO.,  New  York 


0 CI  I  Jl  01 II  /Metabolic  ferment \ 

ULLLnOlll  \ Derived  from  Fungi/ 

A  dependable  influencer  of  nutrition 
clinically  efficient  in  malnutrition  as  is 
 nothing  else  

Produces  These  Important  Effects 

IN  EARLY  TUBERCULOSIS 

Unmistakably  increases  the  blood  count. 
Enables  the  system  to  metabolize  carbo- 
hydrates and  fats.  Increases  appetite 
 and  weight  

Scientific  Rationale 

MEAD  JOHNSON  &  GO. 

on  Request  JERSEY  CITY      -      -      NEW  JERSEY 


SMITHSONIAN  INSTITUTION  LIBRARIES 


3  9088  01225  0312 


THERAPEUTIC  OBSTACLES 

Overcome  by  Bayer  Products 


SAJODIN 

Well-Tolerated  Iodide 

THYRESOL 

Santal  Oil  minus  its  Disadvantages 

CORYFIN 

'  Prolonged  Acting  Menthol 


SABROMIN 

Palatable  and  Active  Bromide 

NOVASPIRIN 

Well-Borne    Salicylate  HELMITOL 

Improved  Hexamethylen-tetramin 

SPIROSAL 

Non-Irritating  Local  Salicylate  IOTHION 

Local  lodin  Absorbent 


£fTT^<\       P.  O.  BOX  2162 

'{BAYEFif 
E 

-  A, 


Samples  and  Literature  Supplied  by 

Farbenfabriken  of  Elberfeld  Co. 

NEW  YORK  117  HUDSON  STREET 


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